- Email: [email protected]
CORONARY RISK FACTORS IN CHILDREN
891
Atrio-ventricular
dissociation
tachycardia. Vl =surface precordial lead fluid column of central venous
in
patient
and Va =modified catheter.
with
precordial
ventricular
NEIL ARMSTRONG lead
through
column of the central venous line (figure). In this clinical setting, we did a prospective study to evaluate the feasibility of right atrial ECG recording through the fluid column of a (correctly positioned) central venous catheter in 100 consecutive intensive care patients with a central venous line already in place. An adequate right atrial ECG was defined as an ECG with a P-wave amplitude more than half the QRS amplitude (Pa/QRSa ratio [ =R] greater than 0-5) or at least twice the maximum P-wave amplitude on surface ECG (Pa greater than 2 Ps). The lead described by Wilson and Gaer resulted in an adequate atrial ECG recording in 88 % of patients (R > 0-5in 65%; Pa > 2 Ps in 23%). The use of lead Va (a precordial lead connected to the fluid column of the central venous line) led to an adequate atrial ECG recording in 96% of patients (R > 0-5 in 75 %; Pa > 2 Ps in 21 %).
D. VOGELAERS Intensive Care Unit, University Hospital, 9000 Gent, Belgium
Our interest in CHD risk factors in children arises from evidence of pathological processes starting in childhood and from the fact that many of the attitudes promoting coronary prone behaviour in adults appear to be rooted in childhood. In adult life there is evidence of social differences in the incidence of CHD and it is beguiling to think that the same social differences may play a part in childhood. Nutrition may well be important but other factors and their interactions must be studied. We should look at how knowledge, attitudes, and social pressures in childhood determine coronary prone behaviour in later life, and do so on large numbers of children followed up for a long time.
J. VANDENBOGAERDE M. D. RIJCKAERT F. COLARDYN
CORONARY RISK FACTORS IN CHILDREN
SiR,—Your March 12 editorial, based on a report from the MRC Environmental Epidemiology Unit, draws attention to the steadily accumulating epidemiological’ and pathologicalz evidence that incriminates childhood factors in the development of coronary heart disease (CHD) in later life. While childhood nutrition may well turn out to be an important, even the most important, factor determining the development of CHD, there is a danger of assuming this prematurely for a disease which in the adult is multifactorial. Epidemiological studies in the United States1,2 and Australia4 indicate that children have similar risk factors for coronary disease as their adult counterparts. So far data from the UK are sparse. We are doing a survey of 600 11-16-year-old children; the results will be available later this year. Our feasibility study in 1986/87 covered 106 children aged 12-13. Although total cholesterol (mean 4-7 mmol/1, 95% confidence interval 44-4-9) and diastolic blood pressure 62 mm Hg (58-66) were within conventionally accepted levels for children of this age, 15% were overweight, 5% were already regular cigarette smokers, and 16% intended to smoke. Activity levels, as defmed by continuous monitoring of pulse rate, were low, with few children achieving levels likely to promote cardiovascular health. Many children had experienced major, potentially stressful, life events. We were especially interested in children’s attitudes to coronary prone behaviour. Half the children knew little about the content of their diet although 65 % knew of some association between fatty food and coronary disease but made little use of this knowledge in deciding what to eat. The social pressures to smoke were highlighted by their conception that most of their friends would approve if they smoked (even if their parents disapproved). Many felt they would like to be physically fitter but appeared unlikely to do much about becoming so. If children on attaining adulthood remain in a similar rank order for the various factors then, with the upper 80th percentile as a guide, two-thirds will have one or more risk factors associated in adult life with CHD.
School of Education and Postgraduate Medical School, University of Exeter, Exeter EX1 2LU
JOHN BALDING PETER GENTLE BRIAN KIRBY
1. Berenson GS, McMahon CA, Voors AW, et al. Cardiovascular risk factors in children: the early natural history of atherosclerosis and hypertension. Oxford: Oxford University Press, 1980. 2. McGill HR Jr. Fatty streaks in the coronary arteries and aorta. Lab Invest 1968; 18: 560-64 3. Lauer RM, Connor WE, Leaverton PE, Reiter MA, Clarke WR. Coronary heart disease risk factors in schoolchildren: the Muscatine study. J Pediatr 1975; 86:
697-705. 4.
Godfrey RC, Stenhouse MS, Cullen KJ,
Blackman V. Cholesterol and the child: Studies of the cholesterol levels of Busselton schoolchildren and their parents. Aust
Paediat J 1972; 8:
72-78.
MOUTH-TO-MASK RESPIRATION
SIR,—Iagree with Dr Brampton and Dr Seidelin and Dr Bridges (March 19, p 650) that the mouth-to-mask technique is the method of choice for initial ventilatory support in the absence of skilled personnel. Indeed, the evidence is overwhelming.1,2 Anaesthetic face-masks (with a pneumatic cuff) are ideal for this purpose because they have a good sized hole to blow through, and the full range of sizes is widely available in all hospitals. Furthermore, anaesthetic-type masks appear to give better results than the "pocket mask’’,2 However, I do find reluctance among hospital personnel to use this technique, because of a fear of becoming infected, especially by HIV. I therefore teach mouth-to-mask respiration with small, commercial, anti-viral breathing filters in line with hospital anaesthetic face-masks. These anti-viral filters are ideal: they fit all anaesthetic face-masks; they have virtually zero resistance; they safely isolate the resuscitator from the patient; they are already widely available in hospital theatre suites and intensive care units; and they are cheap. Since I have been using this mask-filter combination, I have not seen any reluctance to use mouth-to-mask respiration. University Department of Anaesthesia, Queens Medical Centre, Nottingham NG7 2UH
R. W. D. NICKALLS
1. Nickalls RWD, Thomson CW. Mouth-to-mask respiration. Br Med J 1986; 292: 1350. 2. Seidelin PH, Stolarek IH, Littlewood DG Comparison of six methods of emergency
ventilation. Lancet 1986; ii: 1274-75.
TAMOXIFEN VERSUS SURGERY IN ELDERLY PATIENTS WITH BREAST CANCER
SIR,-Mr Gazet and colleagues (March 26, p 679) conclude that tamoxifen alone is as good as other therapy for breast cancer in elderly women by a comparison with lumpectomy only. No reference is made to the results of best conventional methods of breast conservation, where local breast relapse rates do not exceed 10% at 3 years,t-3 bur rather two methods of therapy were compared with 25—38% relapse rates at 3 years (and presumably 100% eventual relapse rates in the tamoxifen group). In a disease where any relapse matters and breast conservation operations are tolerated by the elderly, we believe that the comparison of lumpectomy plus radiotherapy (best conventional therapy) versus lumpectomy plus tamoxifen is far more relevant. We have studied 167 patients with a minimum follow-up of 12 months and median follow-up of 33 months. Of 147 patients
Atrio-ventricular
dissociation
tachycardia. Vl =surface precordial lead fluid column of central venous
in
patient
and Va =modified catheter.
with
precordial
ventricular
NEIL ARMSTRONG lead
through
column of the central venous line (figure). In this clinical setting, we did a prospective study to evaluate the feasibility of right atrial ECG recording through the fluid column of a (correctly positioned) central venous catheter in 100 consecutive intensive care patients with a central venous line already in place. An adequate right atrial ECG was defined as an ECG with a P-wave amplitude more than half the QRS amplitude (Pa/QRSa ratio [ =R] greater than 0-5) or at least twice the maximum P-wave amplitude on surface ECG (Pa greater than 2 Ps). The lead described by Wilson and Gaer resulted in an adequate atrial ECG recording in 88 % of patients (R > 0-5in 65%; Pa > 2 Ps in 23%). The use of lead Va (a precordial lead connected to the fluid column of the central venous line) led to an adequate atrial ECG recording in 96% of patients (R > 0-5 in 75 %; Pa > 2 Ps in 21 %).
D. VOGELAERS Intensive Care Unit, University Hospital, 9000 Gent, Belgium
Our interest in CHD risk factors in children arises from evidence of pathological processes starting in childhood and from the fact that many of the attitudes promoting coronary prone behaviour in adults appear to be rooted in childhood. In adult life there is evidence of social differences in the incidence of CHD and it is beguiling to think that the same social differences may play a part in childhood. Nutrition may well be important but other factors and their interactions must be studied. We should look at how knowledge, attitudes, and social pressures in childhood determine coronary prone behaviour in later life, and do so on large numbers of children followed up for a long time.
J. VANDENBOGAERDE M. D. RIJCKAERT F. COLARDYN
CORONARY RISK FACTORS IN CHILDREN
SiR,—Your March 12 editorial, based on a report from the MRC Environmental Epidemiology Unit, draws attention to the steadily accumulating epidemiological’ and pathologicalz evidence that incriminates childhood factors in the development of coronary heart disease (CHD) in later life. While childhood nutrition may well turn out to be an important, even the most important, factor determining the development of CHD, there is a danger of assuming this prematurely for a disease which in the adult is multifactorial. Epidemiological studies in the United States1,2 and Australia4 indicate that children have similar risk factors for coronary disease as their adult counterparts. So far data from the UK are sparse. We are doing a survey of 600 11-16-year-old children; the results will be available later this year. Our feasibility study in 1986/87 covered 106 children aged 12-13. Although total cholesterol (mean 4-7 mmol/1, 95% confidence interval 44-4-9) and diastolic blood pressure 62 mm Hg (58-66) were within conventionally accepted levels for children of this age, 15% were overweight, 5% were already regular cigarette smokers, and 16% intended to smoke. Activity levels, as defmed by continuous monitoring of pulse rate, were low, with few children achieving levels likely to promote cardiovascular health. Many children had experienced major, potentially stressful, life events. We were especially interested in children’s attitudes to coronary prone behaviour. Half the children knew little about the content of their diet although 65 % knew of some association between fatty food and coronary disease but made little use of this knowledge in deciding what to eat. The social pressures to smoke were highlighted by their conception that most of their friends would approve if they smoked (even if their parents disapproved). Many felt they would like to be physically fitter but appeared unlikely to do much about becoming so. If children on attaining adulthood remain in a similar rank order for the various factors then, with the upper 80th percentile as a guide, two-thirds will have one or more risk factors associated in adult life with CHD.
School of Education and Postgraduate Medical School, University of Exeter, Exeter EX1 2LU
JOHN BALDING PETER GENTLE BRIAN KIRBY
1. Berenson GS, McMahon CA, Voors AW, et al. Cardiovascular risk factors in children: the early natural history of atherosclerosis and hypertension. Oxford: Oxford University Press, 1980. 2. McGill HR Jr. Fatty streaks in the coronary arteries and aorta. Lab Invest 1968; 18: 560-64 3. Lauer RM, Connor WE, Leaverton PE, Reiter MA, Clarke WR. Coronary heart disease risk factors in schoolchildren: the Muscatine study. J Pediatr 1975; 86:
697-705. 4.
Godfrey RC, Stenhouse MS, Cullen KJ,
Blackman V. Cholesterol and the child: Studies of the cholesterol levels of Busselton schoolchildren and their parents. Aust
Paediat J 1972; 8:
72-78.
MOUTH-TO-MASK RESPIRATION
SIR,—Iagree with Dr Brampton and Dr Seidelin and Dr Bridges (March 19, p 650) that the mouth-to-mask technique is the method of choice for initial ventilatory support in the absence of skilled personnel. Indeed, the evidence is overwhelming.1,2 Anaesthetic face-masks (with a pneumatic cuff) are ideal for this purpose because they have a good sized hole to blow through, and the full range of sizes is widely available in all hospitals. Furthermore, anaesthetic-type masks appear to give better results than the "pocket mask’’,2 However, I do find reluctance among hospital personnel to use this technique, because of a fear of becoming infected, especially by HIV. I therefore teach mouth-to-mask respiration with small, commercial, anti-viral breathing filters in line with hospital anaesthetic face-masks. These anti-viral filters are ideal: they fit all anaesthetic face-masks; they have virtually zero resistance; they safely isolate the resuscitator from the patient; they are already widely available in hospital theatre suites and intensive care units; and they are cheap. Since I have been using this mask-filter combination, I have not seen any reluctance to use mouth-to-mask respiration. University Department of Anaesthesia, Queens Medical Centre, Nottingham NG7 2UH
R. W. D. NICKALLS
1. Nickalls RWD, Thomson CW. Mouth-to-mask respiration. Br Med J 1986; 292: 1350. 2. Seidelin PH, Stolarek IH, Littlewood DG Comparison of six methods of emergency
ventilation. Lancet 1986; ii: 1274-75.
TAMOXIFEN VERSUS SURGERY IN ELDERLY PATIENTS WITH BREAST CANCER
SIR,-Mr Gazet and colleagues (March 26, p 679) conclude that tamoxifen alone is as good as other therapy for breast cancer in elderly women by a comparison with lumpectomy only. No reference is made to the results of best conventional methods of breast conservation, where local breast relapse rates do not exceed 10% at 3 years,t-3 bur rather two methods of therapy were compared with 25—38% relapse rates at 3 years (and presumably 100% eventual relapse rates in the tamoxifen group). In a disease where any relapse matters and breast conservation operations are tolerated by the elderly, we believe that the comparison of lumpectomy plus radiotherapy (best conventional therapy) versus lumpectomy plus tamoxifen is far more relevant. We have studied 167 patients with a minimum follow-up of 12 months and median follow-up of 33 months. Of 147 patients