- Email: [email protected]
Ischaemic heart disease-alcohol consumption and genetics
41
Notes
Vitamins
and cancer.
Although it has been hypothesized that large intakes of antioxidant vitamins C, E, and A reduce the risk of breast cancer, few prospective data are available. We prospectively studied 89,494 women members of the Nurses’ Health Study who were 34-59 years old in 1980 and who had not been diagnosed as having cancer. Their intakes of vitamins C, E, and A from foods and supplements were assessed at baseline and in 1984 with the use of a validated semi-quantitative food-frequency questionnaire. Breast cancer was diagnosed in 1439 women during eight years of follow-up. After multivariate adjustment for known risk factors, the relative risk among women in the highest quintile group for intake of vitamin C as compared with the risk among those in the lowest quintile group was 1.03 (95% confidence interval, 0.87 to 1.21); for vitamin E, after vitamin A intake had been controlled for, the relative risk was 0.99 (95% confidence interval, 0.83 to 1.19). In contrast, among women in the highest quintile group for intake of total vitamin A, the relative risk was 0.84 (95% confidence interval, 0.71 to 0.98; P for trend = 0.001). Among women in the lowest quintile group for intake of vitamin A from food, consumption of vitamin A from supplements was associated with a reduced risk (P = 0.03). The significant inverse association of vitamin A intake with the risk of breast cancer was also found on study of data based on the 1984 questionnaire and four years of follow-up. Large intakes of vitamin C or E did not protect women in our study from breast cancer. A low intake of vitamin A may increase the risk of this disease; any benefit of vitamin A supplements may be limited to women with diets low in vitamin A. D Hunter(1) BrighamandWomen’sHospital, Boston,MA 02115,USA Vitamin
K and childhood
cancer.
K vitamin prohylaxis is important for the neonate in order to prevent bleeding. Intramuscular administration is regarded as more efficient than oral administration, notably for late bleedings. Last summer, an English study suggested that intramuscular K vitamin prophylaxis doubled the risk of childhood cancer. Using Swedish population registries (a Medical Birth Registry and a Cancer Registry) we studied childhood cancer in term infants born between 1973 and 1989 in non-instrumental deliveries and developing cancer (and (1) N Engl J
Med
(1993) 329, 234
specifically leukemia) before the end of 1991. lnformation on the mode of K vitamin prophylaxis was obtained from the delivery hospitals. We found no signs of an increased cancer risk following intramuscular prophylaxis. B wlen (2) Universityof Lund, S-22362 Lund,Sweden Analgesia and sedation preceding invasive procedures children undergoing intensive care.
in
Many invasive procedures used in the intensive care of children are inadequately audited or supported by analgesia or sedation. A study of 96 children who spent 3 days or more in a Paediatric Intensive Care Unit showed that of a total of 181 invasive procedures recorded, 50 (28%) had been carried out without additional analgesia or sedation, and during 72% of these 50, the child grimaced or cried. An adverse response occurred in 49% of procedures. The clinical notes of 55 of the children were examined for procedures that had not been recorded, and 318 unrecorded procedures were discovered. In a random sample of 9 of the 41 patients admitted, but in whom no invasive procedures were charted, examination of the hospital notes identified 43 procedures which had taken place. Every child in intensive care should have a single paediatrician who cares for him/her as a whole person, and who ensures that each invasive procedure is performed only when it is absolutely essential. Children may themselves be unable to limit the procedures, or insist upon adequate analgesia. We have observed that some children having prolonged intensive care can behave as if they have suffered a non accidental injury, and an audit of procedures by a designated paediatrician should hopefully reduce the risk of this problem. DPSouthall(3) NorthStaffordshire Hospital,StokeonTrent. Stat-for&hire. ST46QG,UK Ischaemic heart disease - alcohol consumption tics.
and gene-
Epidemiological studies have shown inconsistent relations between alcohol consumption and risk of ischaemic heart disease (IHD). One explanation might be genetic differences between the ethnic populations (2) BUI (1993) 307, 89 (3) BUJ (1993) 306, 1512
42 studied. The Lewis blood group phenotypes are quite differently distributed within different populations. In the Copenhagen Male Study we have previously found an increased risk of ischaemic heart disease (IHD) in men with the Lewis blood group phenotype Le(a-b-). We investigated the association between alcohol consumption, Lewis phenotypes and risk of IHD. Some 2929 men aged 53 to 75 years free from cardiovascular disease at baseline had their morbidity and mortality recorded for a period of four years. The following potential confounders were taken into account: physical activity, tobacco smoking, serum cotinine, serum lipids, body mass index, blood pressure, social class, hypertension, and non-insulin dependent diabetes mellitus. In 280 (9.6%) men with Le(a-b-), alcohol was the only risk factor associated with risk of IHD. There was a significant inverse dose-effect relationship between alcohol consumption and risk of non-fatal + fatal IHD: P = 0.03; for risk of fatal IHD: P = 0.02; in men with other phenotypes, N = 2,649 (90.4%) associations were limited and not significant. In men consuming O-10 alcoholic beverages/week, compared to others, Le(a-b-) had a relative risk (95% confidence interval) of fatal IHD of RR = 8.3 (2.6-26.3). P = 0.0002, of all IHD events, RR = 2.8 (1.3-5.8). P = 0.02, and of all causes of mortality, RR = 2.3 (1.2-4.3), P = 0.02. In conclusion, alcohol consumption was associated with an especially strong reduction of IHD in Le(a-b-) men. This observation might contribute considerably to the explanation of inconsistencies in previous epidemiological studies on the association between alcohol consumption and risk of IHD. HO Hein (1) Rigs hospitalet, University Hospital, DK 2200, Denmark
Conclusion - Steroids are frequently prescribed for cancer patients. Communication concerning the rationale for their use and the planned regime is often deficient both between doctors, and between doctor and patient. The frequent lack of perceived benefit and the possibility of adverse effects suggests the need to monitor closely the response to steroids in patients with advanced cancer. RF Lennard (2) Manorlands Hospice, West Yorks BD 22 9HJ, UK Lipoprotein (a) and risk for the development artery disease in transplant recipients.
High concentrations of serum lipoprotein (a) (Lp(a)) are associated with an increased risk of atherosclerotic vascular disease in the non-transplanted population. However, its relation with accelerated coronary artery disease (CAD) in cardiac transplant recipients has not been reported. We measured serum Lp(a) in 130 cardiac transplant recipients undergoing routine follow-up, which included annual coronary angiography. The median Lp(a) concentration in 33 patients with CAD was 71 mg/dl, which was significantly higher than the corresponding value of 22 mg/dL in the 97 patients without CAD (P = 0.0006). Multivariant analysis showed the serum Lp(a) value to be a higher significant risk factor for CAD irrespective of the other factors included in the regression analysis. Thus, a high concentration of serum Lp(a) is an important, independent risk factor for the development of accelerated CAD in transplant recipients. M Barbir (3) Hamfield Hospital, Harefield, Middlesex UB9 6JH, UK
Steroids and cancer. Design - Survey of 100 consecutive patients with advanced cancer admitted to a hospice. Main’ Outcome Measures - Incidence, rationale and duration of steroid use; patients’ knowledge of their steroid medication; patients’ perception of benefit. Results - 33 patients were taking steroids at the time of admission, with a wide range in duration of use. Only two of the 23 patients admitted via their GP or hospital doctor were accompanied by documentation giving adequate information about their steroid medication. In four, the reason for steroid prescription could not be identified. The commonest reason for use was weakness/anorexia. Only 29% of patients felt the steroids had been beneficial. Eighteen percent of patients had distressing side effects attributable to prolonged steroid use. Only 29% knew that stopping steroids might suddenly be dangerous. (1) Lancer (1993) 341, 392
of coronary
Corticosteroid
osteoporosis:
prevention.
Treatment with calcium and calcitrial reduces bone loss in the lumbar spine in patients receiving therapy, suggesting that the incidence of vertebral fractures related to steroid treatment can be reduced. In a 2-year study conducted at St Vincent’s Hospital, Sydney, Australia, 92 patients who had recently begun treatment with corticosteroids (mean dose 13.5 mglday) for the treatment of rheumatic immunological or respiratory diseases were randomised to either calcium, calcium and calcitrial or calcium, calcitrial and calcitonin. Bone loss occurred in the lumbar spine in the group receiving calcium alone but was prevented or reduced in the other two groups. There was no apparent advantage in the group which received calcitonin in addition to the cal(2) BMJ (1992) 305, 999 (3) Lancer (1992) 340, 1500
Notes
Vitamins
and cancer.
Although it has been hypothesized that large intakes of antioxidant vitamins C, E, and A reduce the risk of breast cancer, few prospective data are available. We prospectively studied 89,494 women members of the Nurses’ Health Study who were 34-59 years old in 1980 and who had not been diagnosed as having cancer. Their intakes of vitamins C, E, and A from foods and supplements were assessed at baseline and in 1984 with the use of a validated semi-quantitative food-frequency questionnaire. Breast cancer was diagnosed in 1439 women during eight years of follow-up. After multivariate adjustment for known risk factors, the relative risk among women in the highest quintile group for intake of vitamin C as compared with the risk among those in the lowest quintile group was 1.03 (95% confidence interval, 0.87 to 1.21); for vitamin E, after vitamin A intake had been controlled for, the relative risk was 0.99 (95% confidence interval, 0.83 to 1.19). In contrast, among women in the highest quintile group for intake of total vitamin A, the relative risk was 0.84 (95% confidence interval, 0.71 to 0.98; P for trend = 0.001). Among women in the lowest quintile group for intake of vitamin A from food, consumption of vitamin A from supplements was associated with a reduced risk (P = 0.03). The significant inverse association of vitamin A intake with the risk of breast cancer was also found on study of data based on the 1984 questionnaire and four years of follow-up. Large intakes of vitamin C or E did not protect women in our study from breast cancer. A low intake of vitamin A may increase the risk of this disease; any benefit of vitamin A supplements may be limited to women with diets low in vitamin A. D Hunter(1) BrighamandWomen’sHospital, Boston,MA 02115,USA Vitamin
K and childhood
cancer.
K vitamin prohylaxis is important for the neonate in order to prevent bleeding. Intramuscular administration is regarded as more efficient than oral administration, notably for late bleedings. Last summer, an English study suggested that intramuscular K vitamin prophylaxis doubled the risk of childhood cancer. Using Swedish population registries (a Medical Birth Registry and a Cancer Registry) we studied childhood cancer in term infants born between 1973 and 1989 in non-instrumental deliveries and developing cancer (and (1) N Engl J
Med
(1993) 329, 234
specifically leukemia) before the end of 1991. lnformation on the mode of K vitamin prophylaxis was obtained from the delivery hospitals. We found no signs of an increased cancer risk following intramuscular prophylaxis. B wlen (2) Universityof Lund, S-22362 Lund,Sweden Analgesia and sedation preceding invasive procedures children undergoing intensive care.
in
Many invasive procedures used in the intensive care of children are inadequately audited or supported by analgesia or sedation. A study of 96 children who spent 3 days or more in a Paediatric Intensive Care Unit showed that of a total of 181 invasive procedures recorded, 50 (28%) had been carried out without additional analgesia or sedation, and during 72% of these 50, the child grimaced or cried. An adverse response occurred in 49% of procedures. The clinical notes of 55 of the children were examined for procedures that had not been recorded, and 318 unrecorded procedures were discovered. In a random sample of 9 of the 41 patients admitted, but in whom no invasive procedures were charted, examination of the hospital notes identified 43 procedures which had taken place. Every child in intensive care should have a single paediatrician who cares for him/her as a whole person, and who ensures that each invasive procedure is performed only when it is absolutely essential. Children may themselves be unable to limit the procedures, or insist upon adequate analgesia. We have observed that some children having prolonged intensive care can behave as if they have suffered a non accidental injury, and an audit of procedures by a designated paediatrician should hopefully reduce the risk of this problem. DPSouthall(3) NorthStaffordshire Hospital,StokeonTrent. Stat-for&hire. ST46QG,UK Ischaemic heart disease - alcohol consumption tics.
and gene-
Epidemiological studies have shown inconsistent relations between alcohol consumption and risk of ischaemic heart disease (IHD). One explanation might be genetic differences between the ethnic populations (2) BUI (1993) 307, 89 (3) BUJ (1993) 306, 1512
42 studied. The Lewis blood group phenotypes are quite differently distributed within different populations. In the Copenhagen Male Study we have previously found an increased risk of ischaemic heart disease (IHD) in men with the Lewis blood group phenotype Le(a-b-). We investigated the association between alcohol consumption, Lewis phenotypes and risk of IHD. Some 2929 men aged 53 to 75 years free from cardiovascular disease at baseline had their morbidity and mortality recorded for a period of four years. The following potential confounders were taken into account: physical activity, tobacco smoking, serum cotinine, serum lipids, body mass index, blood pressure, social class, hypertension, and non-insulin dependent diabetes mellitus. In 280 (9.6%) men with Le(a-b-), alcohol was the only risk factor associated with risk of IHD. There was a significant inverse dose-effect relationship between alcohol consumption and risk of non-fatal + fatal IHD: P = 0.03; for risk of fatal IHD: P = 0.02; in men with other phenotypes, N = 2,649 (90.4%) associations were limited and not significant. In men consuming O-10 alcoholic beverages/week, compared to others, Le(a-b-) had a relative risk (95% confidence interval) of fatal IHD of RR = 8.3 (2.6-26.3). P = 0.0002, of all IHD events, RR = 2.8 (1.3-5.8). P = 0.02, and of all causes of mortality, RR = 2.3 (1.2-4.3), P = 0.02. In conclusion, alcohol consumption was associated with an especially strong reduction of IHD in Le(a-b-) men. This observation might contribute considerably to the explanation of inconsistencies in previous epidemiological studies on the association between alcohol consumption and risk of IHD. HO Hein (1) Rigs hospitalet, University Hospital, DK 2200, Denmark
Conclusion - Steroids are frequently prescribed for cancer patients. Communication concerning the rationale for their use and the planned regime is often deficient both between doctors, and between doctor and patient. The frequent lack of perceived benefit and the possibility of adverse effects suggests the need to monitor closely the response to steroids in patients with advanced cancer. RF Lennard (2) Manorlands Hospice, West Yorks BD 22 9HJ, UK Lipoprotein (a) and risk for the development artery disease in transplant recipients.
High concentrations of serum lipoprotein (a) (Lp(a)) are associated with an increased risk of atherosclerotic vascular disease in the non-transplanted population. However, its relation with accelerated coronary artery disease (CAD) in cardiac transplant recipients has not been reported. We measured serum Lp(a) in 130 cardiac transplant recipients undergoing routine follow-up, which included annual coronary angiography. The median Lp(a) concentration in 33 patients with CAD was 71 mg/dl, which was significantly higher than the corresponding value of 22 mg/dL in the 97 patients without CAD (P = 0.0006). Multivariant analysis showed the serum Lp(a) value to be a higher significant risk factor for CAD irrespective of the other factors included in the regression analysis. Thus, a high concentration of serum Lp(a) is an important, independent risk factor for the development of accelerated CAD in transplant recipients. M Barbir (3) Hamfield Hospital, Harefield, Middlesex UB9 6JH, UK
Steroids and cancer. Design - Survey of 100 consecutive patients with advanced cancer admitted to a hospice. Main’ Outcome Measures - Incidence, rationale and duration of steroid use; patients’ knowledge of their steroid medication; patients’ perception of benefit. Results - 33 patients were taking steroids at the time of admission, with a wide range in duration of use. Only two of the 23 patients admitted via their GP or hospital doctor were accompanied by documentation giving adequate information about their steroid medication. In four, the reason for steroid prescription could not be identified. The commonest reason for use was weakness/anorexia. Only 29% of patients felt the steroids had been beneficial. Eighteen percent of patients had distressing side effects attributable to prolonged steroid use. Only 29% knew that stopping steroids might suddenly be dangerous. (1) Lancer (1993) 341, 392
of coronary
Corticosteroid
osteoporosis:
prevention.
Treatment with calcium and calcitrial reduces bone loss in the lumbar spine in patients receiving therapy, suggesting that the incidence of vertebral fractures related to steroid treatment can be reduced. In a 2-year study conducted at St Vincent’s Hospital, Sydney, Australia, 92 patients who had recently begun treatment with corticosteroids (mean dose 13.5 mglday) for the treatment of rheumatic immunological or respiratory diseases were randomised to either calcium, calcium and calcitrial or calcium, calcitrial and calcitonin. Bone loss occurred in the lumbar spine in the group receiving calcium alone but was prevented or reduced in the other two groups. There was no apparent advantage in the group which received calcitonin in addition to the cal(2) BMJ (1992) 305, 999 (3) Lancer (1992) 340, 1500