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Background and Purpose— Despite previous investigations, substantial uncertainty remains about the relation between body mass index (BMI) and stroke, especially in populations with a relatively low BMI but a high stroke rate. Methods— A nationally representative prospective study of mortality included 212 000 Chinese men 40 to 79 years old without known cardiovascular disease in 1990 to 1991 who were followed up for 10 years. Standardized hazard ratios were calculated for stroke mortality by baseline systolic blood pressure (SBP) and BMI. Results— Mean SBP and BMI were 124 mm Hg and 21.7 kg/m 2 , respectively. During 10 years of follow-up, 5766 stroke deaths were recorded. There were strong, positive relations between BMI and SBP and between SBP and stroke mortality, with a 3-mm Hg higher baseline SBP associated with a 5.6% (95% CI, 5.3% to 6.0%; P 25 kg/m 2 ( P 2 , and among them, BMI was not associated with stroke mortality despite its strong association with BP (which continued to a BMI 2 ). The relation with BMI was similar for ischemic and hemorrhagic stroke but appeared to be steeper among lifelong nonsmokers than among current smokers ( P =0.01 for difference between slopes) despite similarly positive relations between BMI and SBP and between SBP and stroke risk in both smoking categories. Conclusions— High BMI was strongly associated with increased stroke mortality only among men who were overweight or obese.

OBJECTIVE: To investigate the association between risk of motor vehicle driver injury and body mass index (BMI). METHODS: In a cohort study of 10 525 New Zealand men and women, BMI was assessed in 1992-1993 (baseline), and data on deaths and hospitalizations for motor vehicle driver injury were obtained by record linkage to national health databases for the period 1988-1998. Hazard ratios (HR) and CI were estimated by Cox regression. RESULTS: During a mean 10.3 years of follow-up, 139 fatal and non-fatal driver injury cases occurred (85 before baseline and 54 after). A U-shaped association was observed between driver injury risk and BMI, both crudely and after adjustment for covariates, which included age, sex, driving exposure, and alcohol intake (P-values for quadratic trend /=28.7 kg/m(2); HR = 2.00, 95% CI: 1.18-3.39) and lowest (

BACKGROUND: In China, there have been few large prospective studies of the associations of body mass index (BMI) with overall and cause-specific mortality that have simultaneously controlled for biases that can be caused by pre-existing disease and smoking. METHODS: Prospective cohort study of 224 064 men, of whom 40 700 died during follow-up between 1990-91 and 2006. Analyses restricted to 142 214 men aged 40-79 years at baseline with no disease history and, to further reduce bias from pre-existing disease, at least 5 years of subsequent follow-up, leaving 17 800 deaths [including 4165 stroke, 1297 coronary heart disease (CHD), 3121 chronic obstructive pulmonary disease (COPD)]. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) per 5 kg/m(2) calculated within either a lower (15 to

Abraham Maslow, Carl Rogers, Rollo May, great psychologists all. What can they teach us about identifying and nurturing creative intelligence?

AIMS: Plasma levels of apolipoprotein B (apoB), the main surface protein on LDL particles, and LDL-C, the amount of cholesterol in those particles, are closely correlated and, considered separately, are positive risk factors. Plasma levels of apolipoprotein A(1), the main surface protein on HDL particles, and HDL-C, the amount of cholesterol in those particles, are also closely correlated with each other and, considered separately, are negative risk factors. The interdependence of these four risk factors is unclear. METHODS AND RESULTS: Case-control study among 3510 acute myocardial infarction patients (without prior vascular disease, diabetes, or statin use) in UK hospitals and 9805 controls. Relative risks (age, sex, smoking, and obesity-adjusted) were more strongly related to apoB than to LDL-C and, given apoB, more strongly negatively related to apoA(1) than to HDL-C. The ratio apoB/apoA(1) was uncorrelated with time since symptom onset in cases, was reproducible in samples collected a few years apart in controls (correlation 0.81), and encapsulated almost all the predictive power of these four measurements. Its effect was continuous, substantial throughout the UK normal range [relative risk, top vs. bottom decile of this ratio, 7.3 (95% CI 5.8-9.2)] and varied little with age. The ratio apoB/apoA(1) was substantially more informative about risk (chi(1)(2) = 550) than were commonly used measures such as LDL-C/HDL-C, total/HDL cholesterol, non-HDL cholesterol, and total cholesterol (chi(1)(2) = 407, 334, 204, and 105, respectively). Given apoB and apoA(1), the relationship with risk of LDL-C was reversed, and this reversal was strengthened by appropriate allowance for random measurement errors in two correlated variables. Given usual apoB, lower LDL-C (consistent with smaller LDL particles) was associated with higher risk (P < 0.0001). During the first 8 h after symptom onset HDL-C increased by about 10%, precluding reliable assessment of the joint relationship of apoA(1) and pre-onset HDL-C with risk in such retrospective case-control studies. CONCLUSION: Apolipoprotein ratios are more informative about risk than lipid fractions are. This suggests that, among lipoprotein particles of a particular type (LDL or HDL), some smaller and larger subtypes differ in their effects on risk. Direct measurements of even more specific subtypes of lipoprotein particles may be even more informative about risk.

Several epidemiological studies have reported on the association between body mass index (BMI) and risk of esophageal cancer, but these were mostly in Western populations where many are overweight or obese. There is little direct evidence about the relationship in China where the mean BMI is relatively low and the disease rate is high. We examined the data from a populationbased prospective study of 220,000 Chinese men aged 40–79 without a previous history of cancer (mean BMI 21.7 kg/m 2 ), which included 1,082 esophageal cancer deaths during 10 years of follow-up. Adjusted hazard ratios for death from esophageal cancer by baseline BMI category were calculated using Cox proportional hazards models. Even among men with good self-assessed health and BMI 18.5 kg/m 2 , there was a strong inverse association between BMI and death from esophageal cancer, with each 5 kg/ m 2 higher BMI associated with 25% (95%CI: 11–36%) lower esophageal cancer mortality. This inverse association persisted when analysis was restricted to men who had never smoked or when the first 5 years of follow-up were excluded. The strength of the relationship was consistent with the pooled estimate for squamous cell carcinoma of the esophagus in a meta-analysis of prospective studies (31% lower relative risk per 5 kg/m 2 higher BMI; 95% CI: 25–37%), but contrasted with that for adenocarcinoma which showed a positive association with BMI. Together, these data provide reliable evidence that in many populations low BMI is associated with an increased risk of squamous cell carcinoma of the esophagus. ' 2007 Wiley-Liss, Inc.

A prospective study of half a million adults living in the city of Chennai (formerly Madras) arose out of discussions at the 1994 International Cancer Congress in Delhi about how to assess the effects of tobacco on health in different parts of India. Chennai is the capital of the South Indian state of Tamil Nadu, and it is India’s fourth most populous city. Two large-scale epidemiological studies of tobacco and other factors were established: a case-control study 1 that could provide reasonably reliable results quickly, and a prospective cohort study that could provide more robust results over a longer period. (A parallel prospective study of 100000 adults, not included in this profile, is in progress in the nearby rural area of Villupuram; Figure 1.) The case-control analyses, 1 which involved 43000 adult deaths during 1995–97 and 35000 controls who had been living with a case, indicated that smoking is a cause of, among other things, about half of all tuberculosis (TB) deaths among men. The prospective cohort study, which recruited half a million participants between 1998 and 2001, is described here.

We evaluated the prevalence of sexually transmitted infections (STI) and their association with self-disclosed risk behaviour in men who have sex with men (MSM) attending a Central London sexual health service for asymptomatic STI screening. Using computer touch screens, attenders enter data including demographics, number of sexual partners in the past 3 months and sexual history. All are asked the following question to assess for high-risk sexual behaviour: ‘Are …

Introduction: Integrase inhibitors (INIs) are the latest class of antiretroviral drugs approved for the treatment of HIV infection and are becoming ‘standard’ drugs in the treatment of both naive as well as heavily pretreated individuals with HIV.Areas covered: Data on efficacy, safety, tolerability, pharmacokinetics, drug-drug interactions and resistance are reviewed from the pivotal Phase III clinical trials published in PubMed high-impact medical journals or presented at international meetings.Expert opinion: Due to their outstanding data of efficacy, tolerability, safety – shared by all three drugs (raltegravir, elvitegravir, dolutegravir) currently belonging to this new family of antiretrovirals – INIs have become part of the recommended initial antiretroviral therapy options. Some differences in dosing, drug-drug interactions and robustness/genetic barrier among the three drugs will provide the physician the characteristics to make the best choice.

OBJECTIVES: to examine the prevalence of vitamin B12 deficiency and folate deficiency in later life in representative samples of the elderly population in the United Kingdom. DESIGN: a population-based cross-sectional analysis of 3,511 people aged 65 years or older from three studies was used to estimate the age-specific prevalence of vitamin B12 deficiency and of folate deficiency. Vitamin B12 deficiency is conventionally diagnosed if serum vitamin B12 < 150 pmol/l ('low vitamin B12'). We defined 'metabolically significant vitamin B12 deficiency' as vitamin B12 < 200 pmol/l and blood total homocysteine >20 micro mol/l. Folate deficiency, which usually refers to serum folate 20 micro mol/l. RESULTS: the prevalence of vitamin B12 deficiency, whether defined as low vitamin B12 or metabolically significant vitamin B12 deficiency increased with age in all three studies, from about 1 in 20 among people aged 65-74 years to 1 in 10 or even greater among people aged 75 years or greater. The prevalence of folate deficiency also increased with age, and was similar to that for vitamin B12 deficiencies, but only about 10% of people with low vitamin B12 levels also had low folate levels. CONCLUSION: the high prevalence of vitamin B12 and folate deficiency observed in older people indicates a particular need for vigilance for deficiency of these vitamins. Reliable detection and treatment of vitamin deficiency could reduce the risk of deficiency-related disability in old age.

STUDY OBJECTIVE: To investigate the association between motor vehicle driver injury and socioeconomic status. DESIGN: Cohort study with prospective and retrospective outcomes. SETTING: New Zealand. PARTICIPANTS: 10 525 adults (volunteer sample of a multi-industry workforce, n=8008; and a random sample of urban electoral rolls, n=2517). OUTCOME MEASURE: Motor vehicle driver injury resulting in admission of the driver to hospital or the driver's death, or both, during the period 1988-98; hospitalisation and mortality data were obtained by record linkage to national health databases. MAIN RESULTS: After adjustment for age and sex, driver injury risk was inversely associated with both occupational status (p for linear trend

Screening and treatment of sexually transmissible infections, including HIV, are free in the UK nations; pre-exposure prophylaxis (PrEP) became free in England in October 2017 through the PrEP Impact trial. Doctor-led PrEP clinics started at 56 Dean Street in September 2015, with the drug purchased privately at full price. The service was expanded to other staff to support initiation and monitoring of increasing numbers of attendees purchasing PrEP from online pharmacies. Nonetheless, when the clinic was given a target of 1700 for the PrEP Impact trial, it was clear this could not be achieved in a timely manner through 56 Dean Street alone. To prepare for the trial, all staff with HIV testing competencies were trained in good clinical practice and trial-specific procedures, and a patient group directive was approved to facilitate nurse prescribing and dispensing. Electronic pro formas to capture eligibility for starting or continuing PrEP were adapted for the Dean Street Express clinic, with some information collected directly from service users using touch screens. These interventions, together with an update to the 2016 information leaflet developed by the community, enabled enrolment and follow-up of 1700 participants in 4 months. PrEP advice and monitoring were easily accommodated in the 56 Dean Street sexual health service, but did require additional training and approval for nurse prescribing and dispensing drug in order to achieve the target, which still fell short of the demand.

INTRODUCTION: Cohort studies have contributed important scientific knowledge regarding the determinants of chronic diseases. Despite the need for etiologic investigations, this design has been infrequently used in injury prevention research. OBJECTIVES: To describe the baseline findings of the New Zealand Blood Donors' Health Study, a large prospective study designed to investigate relationships between lifestyle, psychosocial factors, and serious injury due to road crashes, falls, self harm, assault, work, sport, and recreation. METHODS: Participants were recruited from fixed and mobile collection sites of a voluntary non-profit blood donor program. Baseline exposure data (for example risk taking behaviors, alcohol and marijuana use, sleep habits, and depression) were collected using a self administered questionnaire. Outcome data regarding serious injury will be collected prospectively through computerized record linkage of participants' unique identifiers to national morbidity and mortality databases. RESULTS: In total, 22 389 participants enrolled in the study (81% response rate). The diverse study population included 36% aged 16-24 years, 20% rural residents, and large variability in exposures of interest. For example, in the 12 months before recruitment, 21% had driven a motor vehicle when they considered themselves over the legal limit for alcohol, and 11% had been convicted of traffic violations (excluding parking infringements). Twelve per cent had seriously considered attempting suicide sometime in their life. CONCLUSIONS: This is the first, large scale cohort study investigating determinants of serious injury in New Zealand and among the largest worldwide. Preliminary findings from prospective analyses that can inform injury prevention policy are expected within five years.

UK post-exposure prophylaxis (PEP) guidelines were updated by the British Association for Sexual Health and HIV (BASHH) in 2011. In 2013, we changed policy to omit day 5 PEP follow-up at 56 Dean Street as it was felt clinically unnecessary. This audit compares our performance against BASHH standards for PEP attenders during June 2012 and June 2013. We identified 162 PEP prescriptions; PEP assessment and appropriate sexually transmitted infection testing was done well. PEP completion rates and post-PEP HIV testing were lower than BASHH standards. Following omission of day 5 review, documentation that results have been checked was poor; however, attendance at follow-up was not adversely affected.

We have resolved a central and long-standing paradox in understanding the amplification of rod phototransduction by making direct measurements of the gains of the underlying enzymatic amplifiers. We find that under optimized conditions a single photoisomerized rhodopsin activates transducin molecules and phosphodiesterase (PDE) catalytic subunits at rates of 120–150/s, much lower than indirect estimates from light-scattering experiments. Further, we measure the Michaelis constant, K m , of the rod PDE activated by transducin to be 10 μM, at least 10-fold lower than published estimates. Thus, the gain of cGMP hydrolysis (determined by k cat / K m ) is at least 10-fold higher than reported in the literature. Accordingly, our results now provide a quantitative account of the overall gain of the rod cascade in terms of directly measured factors.

We examined the responses of toad rod photoreceptors to single photons of light. To minimize the effects of variability in the early rising phase, we selected sets of responses that closely matched the rise of the mean single photon response. Responses selected in this way showed substantial variations in kinetics, appearing to peel off from a common time course after different delays. Following incorporation of the calcium buffer BAPTA, the time to peeling off was retarded. Our analysis indicates that it is not necessary to invoke a long series of reaction steps to explain the shutoff of rhodopsin activity. Instead, our results suggest that the observed behavior is explicable by the presently known shutoff reactions of activated rhodopsin, modulated by feedback.

We describe the characteristics of HIV post-exposure prophylaxis (PEP) recipients and PEP indications at 56 Dean Street, a central London sexual health clinic. PEP was prescribed on 577 occasions. Most (97%) was given for unprotected anal intercourse. Over a fifth of exposures involved recreational drug use. Of the patients prescribed PEP, 5.9% were given PEP more than once in this period. As a snapshot of HIV risk behaviour, we note the prevalence of drug use, sex without condom use and group sex among PEP recipients.

Background: Few large studies in China have investigated total physical activity and sedentary leisure time and their associations with adiposity. Objective: We investigated determinants of physical activity and sedentary leisure time and their associations with adiposity in China. Design: A total of 466,605 generally healthy participants (age: 30–79 y, 60% female) in the China Kadoorie Biobank were included in this cross-sectional analysis. Self-reported information on a range of activities was collected by interviewer-administered questionnaire. Physical activity was calculated as metabolic equivalent task hours per day (MET-h/d) spent on work, transportation, housework, and nonsedentary recreation. Sedentary leisure time was quantified as hours per day. Adiposity measures included BMI, waist circumference, and percentage body fat (by bioimpedance analysis). Associations were estimated by linear and logistic regression. Results: The mean physical activity was 22 MET-h/d, and the mean sedentary leisure time was 3.0 h/d. For each sex, physical activity was about one-third lower among professionals/administrators than among factory workers, with intermediate levels for other occupational categories. A 1-SD (14 MET-h/d) greater physical activity was associated with a 0.15-unit (95% CI: 0.14, 0.16) lower BMI (in kg/m 2 ), a 0.58-cm (95% CI: 0.55, 0.61) smaller waist circumference, and 0.48 (95% CI: 0.45, 0.50) percentage points less body fat. In contrast, a 1-SD (1.5 h/d) greater sedentary leisure time was associated with a 0.19-unit higher BMI (95% CI: 0.18, 0.20), a 0.57cm larger waist circumference (95% CI: 0.54, 0.59), and 0.44 (95% CI: 0.42, 0.46) percentage points more body fat. For any given physical activity level, greater sedentary leisure time was associated with a greater prevalence of increased BMI, as was lower physical activity for any given sedentary leisure time. Conclusions: In adult Chinese, physical activity varies substantially by occupation, and lack of physical activity and excess sedentary leisure time are independently and jointly associated with greater adiposity. Am J Clin Nutr doi: 10.3945/ajcn.112.046854.

Background: Stroke is a leading cause of disability and premature death in China and blood pressure is widely considered to be a major cause. Despite this, substantial uncertainty remains about the shape and strength of the association between blood pressure and stroke pathological types in China. Methods: Information from the China Kadoorie Biobank study (a prospective cohort study of 0.5 million men and women in China recruited during 2004-8) was used to relate usual blood pressure to risk of stroke, by stroke pathological type (cerebral infarction [ischaemic stroke], intracerebral haemorrhage and subarachnoid haemorrhage). Prospective analyses excluded participants with a history of vascular disease recorded at baseline; involved correction for regression dilution bias; used incident stroke events for which the diagnosis involved a head CT or MRI scan; and, assessed for confounding and effect modification by major vascular risk factors. These prospective analyses were informed by a set of prior analyses, including: a description of baseline associations between blood pressure and other vascular risk factors, to identify potential confounders; analyses of resurvey blood pressure data from ~20_000 participants, to assess regression dilution bias; and analyses of stroke follow-up data, involving an adjudication ‘sub-study’ performed specifically as part of this thesis, to evaluate the diagnostic accuracy of incident stroke events (~1000 events were adjudicated). Results: During 2.1 million person-years at risk, there were 5783 incident stroke events. At ages 40-79 years, the proportional difference in risk of both cerebral infarction and intracerebral haemorrhage associated with a given absolute difference in usual blood pressure was constant throughout the range of blood pressures examined (SBP 120-170 mm Hg, DBP 70-100 mm Hg). Overall, the strength of association was approximately 1.5-times greater for intracerebral haemorrhage than for the other stroke pathological types: 10 mm Hg higher usual SBP was associated with 82% (95% CI: 76%-89%) higher risk of intracerebral haemorrhage, 47% (44%- 50%) higher risk of cerebral infarction and 52% (35%-71%) higher risk of subarachnoid haemorrhage (the overall mean age at event for each stroke pathological type was ~60 years). For both cerebral infarction and intracerebral haemorrhage, there was strong evidence of major effect modification by age and to a lesser extent by a number of other vascular risk factors. The associations by age were around a third as extreme at age 70-79 years than at 40-49 years. The annual absolute differences in risk associated with a given absolute increase in usual blood pressure, however, were greater at older age. Conclusions: In Chinese adults, usual blood pressure was strongly and positively related to risk of all stroke pathological types. The strength of association was greater for intracerebral haemorrhage than other stroke pathological types. For both cerebral infarction and intracerebral haemorrhage, there was evidence of major effect modification by age. The overall effect of blood pressure on stroke risk was much greater than estimated by previous prospective studies in China, particularly for intracerebral haemorrhage.

Background Understanding the risk factors for HIV acquisition allows targeted interventions to reduce HIV transmission such as PrEP. Aims/Objectives To evaluate HIV incidence in HIV-negative MSM with early syphilis infection. Methods A retrospective case-note review of MSM who were diagnosed with early syphilis between January and June 2014 at a London sexual health clinic. Results 206 MSM were diagnosed with early syphilis: 110 HIV-negative; 96 HIV-positive. For 110 HIV-negative MSM, median age was 32 y, median number of sexual partners in last 3 months was 4. Reported drug use in the previous month was 38%; 19% had injected drugs. Syphilis stage was primary (31%), secondary (25%), early latent (45%).Up to February 2016, total follow-up was 144 person-years. 12 (11%) were newly diagnosed HIV-positive. HIV incidence was 8.3 (95% confidence interval, CI 4.2–14) per 100 person-years follow-up (HPYFU). Incidence of rectal STIs was: rectal chlamydia, 27 HPYFU (CI 19–36); rectal gonorrhoea, 33 HPYFU (CI 25–44); syphilis re-infection, 10 HPYFU (CI 5.7–17). Conclusions The significant risk of HIV seroconversion following a diagnosis of early syphilis suggests that this group may particularly benefit from the use of pre-exposure prophylaxis. The high levels of subsequent rectal infections support the inclusion of regular STI screening in PrEP management guidelines.

Background/introduction Whilst guidelines recommend NG TOC 2 weeks after treatment, there is little data on the optimum time to perform a TOC for CT in those for whom this is indicated. Current BASHH guidelines recommend deferring TOC for at least 3 weeks after treatment because residual chlamydial DNA may persist. Aim(s)/objectives Patients who are treated for NG and CT co-infection re-attending for subsequent NG TOC are tested for both infections by NAAT providing the opportunity to evaluate the CT positivity rate at re-attendance. Methods A retrospective case review of co-infected GC/CT positive (analysed with Cepheid GeneXpert) patients tested in a’London sexual health clinic over 12 consecutive months was’performed. TOC details were evaluated, and appropriate antibiotic treatment according to BASHH guidelines was assessed. Results 480 patients tested positive for both infections and 132 attended for TOC within 21 days of treatment (median 15 days, IQR 14–17). Of these 131 were male, of whom 126 MSM; median age was 35 y and median number of sexual partners in previous 3 months was 5. Site of CT infection was rectal (94), urethral (49), throat (11), vulvovaginal (1). At TOC, 6 (4.5%) had a persistent positive CT NAAT: rectum (3), urethra (3). One patient with persistent rectal CT had received treatment with azithromycin; the other 5 received BASHH preferred treatment. By comparison, 3 (2.3%) had a positive NG NAAT at TOC. Discussion CT positivity 15 days after treatment is low, suggesting that TOC at 2 weeks may be a possible management strategy.

Background/introduction Truvada® (TDF/FTC) PrEP taken daily or intermittently reduces HIV acquisition by over 86%. However, PrEP is only available privately in the UK, costing upwards of £400 for 30 tablets. Online generic TDF/FTC is significantly cheaper at £35-£50 for 30 tablets. There are, however, authenticity concerns about online medicines. Additionally, HIV infection should be excluded in individuals taking PrEP and baseline assessments of hepatitis B and renal function performed which may not occur with online PrEP. Since February 2016, we have provided assessment and therapeutic drug monitoring to individuals on generic TDF/FTC to ensure safety and medication integrity. Aim(s)/objectives To review characteristics of individuals taking generic TDF/FTC. Methods Service evaluation of individuals taking generic TDF/FTC attending a London sexual health service. Data on the first 44 patients were collected: demographics, HIV and renal function testing, hepatitis B status, baseline STIs, regimen, source of PrEP. Results All MSM; mean age 41 years (28–73); 77% White; 33/44 (75%) on PrEP at time of attendance; all HIV antibody negative prior to commencement. Mean eGFR 81.5 ml/min, 65% had documented hepatitis B immunity. One STI (syphilis) was identified at baseline. 93% were taking daily PrEP and 86% obtained Cipla manufactured Tenvir-EM® from United Pharmacies. Tenofovir and FTC levels were measured in 18/44 (41%), all results demonstrating presence of adequate active compound. Discussion/conclusion Numbers of individuals requiring monitoring on generic TDF/FTC are increasing. It is reassuring that so far, drug levels suggest appropriate quantities of tenofovir and FTC in Tenvir-EM®; however, more data are needed.

OBJECTIVE: The objective of this work was to describe the relationships between educational level, tobacco chewing, and cancer mortality in south India, among middle-aged adults who never smoked tobacco or drank alcohol, to eliminate confounding by those habits. METHODS: This case-control study was conducted in two areas of Tamil Nadu state. The cases studied were 2,580 lifelong non-smoking non-drinkers who died at age 35-69 years during 1995-1998, with interviews in 1998-2000 of a spouse, neighbour, or close associate, who retrospectively provided information on the education and chewing/other habits of the deceased. Underlying neoplastic cause of death was determined by verbal autopsy. The controls were 429,306 lifelong non-smoking non-drinkers aged 35-69 from these two study areas, interviewed during 1998-2001. RESULTS: Among the controls, prevalence of current tobacco chewing was much higher in those with less education, irrespective of sex, urban/rural residence, or birth year. Compared with never chewers, ever chewers had fivefold higher mortality from mouth cancer (odds ratio 4.9, 95% confidence interval 3.5-6.8), and 1.5 to twofold higher mortality from cancers of the pharynx/larynx/oesophagus combined, stomach, and cervix. Each of these cancers had a strong, independent, inverse association with educational level. CONCLUSION: This study supports a substantial body of evidence that tobacco chewing can cause mouth cancer, and adds to evidence that chewing may increase the risk of cancer at other sites. The analysis suggests a possible link with cervical cancer, but this could have been because of residual confounding by social factors. Avoidance of tobacco chewing would avert many cancer deaths in south India, especially for people who have received relatively little formal education.

The UK Health Protection Agency (HPA) estimates that 26% of the UK population infected with HIV are undiagnosed.1 This is estimated using data sources including HIV testing of unlinked anonymised blood samples taken for syphilis testing from attenders at 16 UK genitourinary medicine clinics, the GUM Anon survey.2 This estimated proportion of undiagnosed HIV infections may be an overestimate caused by individuals who are aware of their HIV infection not reporting this when testing for sexually transmitted infections (STIs).3 We conducted a …

Random errors in the measurement of 10 commonly investigated cardiovascular risk factors (systolic and diastolic blood pressure, blood cholesterol, blood glucose, pulse rate, body mass index (BMI), cigarette consumption, passive smoking, alcohol intake and physical exercise) were assessed in a general population cohort (n = 2517) and a workforce cohort (n = 8008). Random errors were estimated from regression dilution ratios (lower ratios imply greater random error, and a ratio of one implies no random error). All of the risk factors, except for BMI (which had regression dilution ratios of 0.93 and 0.98 in the two cohorts), were measured with substantial levels of random error. Particularly low regression dilution ratios were observed for physical exercise (0.28 and 0.39) and pulse rate (0.47 and 0.56). For each of these risk factors, with the possible exception of BMI, associations with long-term average values could be importantly biased toward the null unless appropriate corrections are made.

Despite more than 80% of the global burden of cardiovascular diseases now occurring in low- and middle-income countries,1 most of what we know about the causes of these diseases comes from studies of populations in North America and Western Europe. Many of the resulting clinical and public health policies in these high-income regions are being applied in lower-income regions, but perhaps sometimes inappropriately, since many lower-income countries have physical, social and economic environments that are substantially different from those in richer parts of the world. Helping to close this gulf in cardiovascular knowledge is the INTERHEART case–control study. Spread across one-quarter of the world’s countries, including 30 or so lower- and middle-income countries, the study is a unique resource for assessing causes of coronary heart disease in different contexts.2 3 4 5 For this reason, and because of its sheer size (12 000 cases of acute myocardial infarction (AMI) and 15 000 controls), INTERHEART has rightly become a landmark study. New INTERHEART findings for China are unveiled in this edition of the journal ( see page 1857 ).6 The 12 000 INTERHEART cases included 3000 in China, and the results for this subgroup are compared with those for the other 51 countries taken together. While all nine main INTERHEART cardiovascular risk factors were associated with MI in the China subgroup, there was significant heterogeneity in the strength of the association for some of these factors between China and the rest. The results suggest that the effects of diabetes and of psychosocial stress may be unusually strong in China, that the effects …

Background While most of the global burden from chronic diseases, and especially vascular diseases, is now borne by low and middle-income countries, few large-scale epidemiological studies of chronic diseases in such countries have been performed. Methods From 1998–2004, 52 584 men and 106 962 women aged ≥35 years were visited in their homes in Mexico City. Self reported diagnoses of chronic diseases and major disease risk factors were ascertained and physical measurements taken. Age- and sex-specific prevalences and means were analysed. Results After about age 50 years, diabetes was extremely common – for example, 23.8% of men and 26.9% of women aged 65–74 reported a diagnosis. By comparison, ischaemic heart disease was reported by 4.8% of men and 3.0% of women aged 65–74, a history of stroke by 2.8% and 2.3%, respectively, and a history of cancer by 1.3% and 2.1%. Cancer history was generally more common among women than men – the excess being largest in middle-age, due to breast and cervical cancer. At older ages, the gap narrowed because of an increasing prevalence of prostate cancer. 51% of men and 25% of women aged 35–54 smoked cigarettes, while 29% of men and 41% of women aged 35–54 were obese (i.e. BMI ≥30 kg/m2). The prevalence of treated hypertension or measured blood pressure ≥140/90 mmHg increased about 50% more steeply with age among women than men, to 66% of women and 58% of men aged 65–74. Physical inactivity was highly prevalent but daily alcohol drinking was relatively uncommon. Conclusion Diabetes, obesity and tobacco smoking are highly prevalent among adults living in Mexico City. Long-term follow-up of this and other cohorts will establish the relevance of such factors to the major causes of death and disability in Mexico.

Background Existing data on the effect of genital discharge and dermatoses on the quality of life (QoL) and sexual function (SF) in women with genital complaints are limited. Objectives To study the impact of our specialist clinic for recurrent genital problems on QoL and SF using two validated questionnaires: dermatology life quality index (DLQI) and female sexual function index (FSFI). Methods All women attending this specialist clinic during 2013 were invited to complete both DLQI and FSFI. Questionnaires were resent six months later or completed at follow-up attendance. Paired questionnaires were analysed using Wilcoxon-signed-rank tests. Results We received 143 responses: 99 dermatological complaints and 44 discharge complaints. Both complaints have a detrimental effect on QoL (mean ± SD quality of life scores 8·4 ± 6·6, moderate effect on QoL vs published general population score between 0 and 1 in validation studies). SF was also impaired (score 19.6 ± 6.9, vs published general population mean score 30.5 ± 5.29). 13 patients fully completed DLQI pre and post clinic intervention; there was significant improvement in DLQI scores (median pre-intervention vs post-intervention scores, interquartile range (IQR): 15 (12–18) vs 8 (6–12), P = 0.013). FSFI scores did not significantly improve (18.55 (16.5–22.5) vs 18.5 (14.0–22.7), P = 1.000). Discussion/conclusion Both QoL and SF are impaired in many women presenting with recurrent genital complaints. Appropriate assessment and management by senior physicians can significantly improve QoL in these women supporting the role of specialist clinics. There remains significant impairment to SF, warranting research into affordable interventions.

Background/introduction The introduction of onsite Cepheid ® GeneXpert diagnostics for asymptomatic STI screens cut ‘test to treatment’ time by 190 h. Aim(s)/objectives To evaluate the Public Health benefit of faster treatment. Methods Patients with chlamydia (CT) and/or gonorrhoea (GC) over 8 weeks in February 2014 were retrospectively identified. We compared the timing of testing, treatment and number of recent sexual partners with a control group from November 2013. Assuming rate of partners remains unchanged, we calculated ‘partners spared’ exposure per infected patient due to faster treatment. Results 431 patients were identified with CT and/or GC infection. 81% (349/431) were MSM. Median age was 29 years. 23% of index patients disclosed high risk behaviour including fisting, chemsex and injecting drug use. Median ‘test to treatment’ time dropped from 238 h to 48 h. The number of partners spared exposure was 0.5 per index case. This equates to a total 196 partners spared exposure over the study period. Discussion/conclusion For every two people diagnosed with an infection, one partner was spared exposure. Limiting the duration of infectivity and the potential for onward transmission has clear public health benefits and is of particular value in this cohort with multiple partners who engage in high-risk behaviour.

Background/introduction BASHH guidelines recommend test-of-cure (TOC) in all cases of N. gonorrhoeae (NG) 2 weeks after treatment. Previously patients re-attended our clinic in person for TOC. To create capacity in the clinic, we introduced NG TOC postal packs for MSM following treatment. Aim(s)/objectives To evaluate TOC return rate and patient satisfaction with the service development. Methods MSM with proven NG were given postal TOC packs at treatment. Each pack contains appropriate NAAT sampling kits for site of diagnosed infection (rectal, throat, urine) and written instructions, patient satisfaction survey and partner notification questionnaire. Patients are instructed to return TOC samples by post in a provided Royal Mail Safebox. We processed samples using our in-house GeneXpert system; results are sent by SMS. Results During November 2014, 136 NG TOC packs were dispensed. 76 (55.9%) patients returned postal packs; 28 (20.6%) attended for TOC in person, giving overall TOC rate, 76.5%. NG TOC rate in October 2014 was 75.8%. The median time from treatment to sending TOC results was 19 d (IQR:16–24d). NG TOC positivity rate was 12.5% (13/104). 65 patient satisfaction surveys were returned. Most responders found postal TOC easy to use (81.5%; 53/65). 24.6% (16/65) responders would have preferred to attend in person for TOC. Discussion/conclusion Postal testing is an acceptable NG TOC method which, when combined with the option to return in person, reduced unnecessary follow-up visits while maintaining TOC return rate. The high TOC positivity rate reinforces the importance of continuing to retest patients with NG after treatment.

BACKGROUND: Increased body mass index (BMI) is known to be related to ischaemic heart disease (IHD) in populations where many are overweight (BMI>or=25 kg/m2) or obese (BMI>or=30). Substantial uncertainty remains, however, about the relationship between BMI and IHD in populations with lower BMI levels. METHODS: We examined the data from a population-based, prospective cohort study of 222,000 Chinese men aged 40-79. Relative and absolute risks of death from IHD by baseline BMI were calculated, standardized for age, smoking, and other potential confounding factors. RESULTS: The mean baseline BMI was 21.7 kg/m2, and 1942 IHD deaths were recorded during 10 years of follow-up (6.5% of all such deaths). Among men without prior vascular diseases at baseline, there was a J-shaped association between BMI and IHD mortality. Above 20 kg/m2 there was a positive association of BMI with risk, with each 2 kg/m2 higher in usual BMI associated with 12% (95% CI 6-19%, 2P=0.0001) higher IHD mortality. Below this BMI range, however, the association appeared to be reversed, with risk ratios of 1.00, 1.09, and 1.15, respectively, for men with BMI 20-21.9, 18-19.9, and

Objective: To investigate the association of marital status with risk of motor vehicle driver injury. Design: A cohort study with prospective and retrospective outcomes. Setting: New Zealand. Participants: A total of 10 525 adults (a volunteer sample of a multi-industry workforce, n = 8008; and a random sample of urban electoral rolls, n = 2517). Exposure variable: Self reported marital status, assessed from a questionnaire administered in 1992–93 (baseline). Main outcome measure: Motor vehicle driver injury resulting in admission of the driver to hospital and/or the driver’s death, during the period 1988–98; hospitalisation and mortality data were obtained by record linkage to national health databases. Results: During 108 741 person-years of follow up, 139 driver injury cases occurred (85 before baseline, 54 after). After adjustment for age, sex, and study cohort, never married participants had twice the risk of driver injury (hazard ratio [HR] 2.06, 95% confidence interval [CI] 1.35 to 3.16) as married participants (HR 1.00). The relative risk for never married participants was slightly higher (HR 2.29), though less precise (95% CI 1.39 to 3.76), after further adjustment for alcohol intake, driving exposure, area of residence, body mass index, and occupational status. Conclusions: After taking age, sex, and other variables into account, never married people had a substantially higher risk of driver injury than married people. While requiring corroboration, these findings imply that it may be appropriate for driver injury countermeasures to be targeted to never married people.

Populations all around the world are becoming more obese, but some are doing so much faster than others. Yet even in seriously affected populations, blood pressure, cholesterol and coronary heart disease death rates continue to fall. Is obesity a trifling matter, or is it just less telling than everything else put together?

Rapid on-site diagnostics permit prompt recognition and treatment of infections. We introduced the GeneXpert system (Cepheid, California, USA) within 56 Dean Street, a central London sexual health clinic. The machine processes Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) samples in 90 min by real-time PCR. We present the results of the service evaluation of a pilot where GeneXpert was used to process samples from individuals attending outreach or specialised clinics. Asymptomatic attenders whose samples were processed using the GeneXpert system were compared with asymptomatic ‘standard of care’ …

Risk equations based on the Framingham Heart Study (FHS) are used in NZ to predict the 5y risk of an incident CV event for individuals without cardiovascular (CV) disease. OBJECTIVES: To establish in a NZ population without overt CV disease: (i) the discriminability of the relevant FHS risk equation for prediction of first hospitalisation or mortality for any cardiovascular event; (ii) whether FHS risk equations have better discriminability than single risk factors. METHODS: Observations were taken from a cohort study with 6354 (4638 M + 1716 F) participants age 32–74 without known CV disease, taken from the workforce of a nation-wide multi-industry corporation plus a random sample of the Auckland electoral rolls. Prognostic factors were assessed in 1992–93 by a questionnaire plus physiological measurements (BP, cholesterol etc.). Outcomes data were CV mortality and hospital discharges from Jan. 1988 to Dec. 1998 (NZ Health Information Service). Risk predictions were compared with outcomes, and receiver-operator characteristics (ROC) curves were constructed. The area under the ROC curve was obtained by fitting a dual-Gaussian unequal variance model. RESULTS: Table 1 shows the area under the ROC curves. CONCLUSIONS: FHS risk equations or age alone provide moderate discriminability for individuals with 5y risk of a CV event that requires hospitalisation. SBP and serum lipids have weaker discriminability. Area under ROC curves (±95% CI). FHS .72 ± .030 .78 ± .055 .74 ± .025 Age .70 ± .029 .77 ± .058 .71 ± .026 SBP .62 ± .034 .69 ± .062 .64 ± .030 Chol/HDLc .61 ± .034 .64 ± .066 .63 ± .030 BMI .56 ± .034 .61 ± .063 .58 ± .029

Background One of the proposed aetiological mechanisms for idiopathic sudden deafness is vascular disease. However, it is not known whether traditional cardiovascular risk factors, such as particular dietary factors, are associated with this condition. Methods A case-control study using pooled controls was conducted in Japan to investigate the relationship between idiopathic sudden deafness and diet. An m:n matchedpairs method was used to obtain age-, gender- and residential district-matched controls from a nationwide database of pooled controls. Food intake was assessed from a self-administered usual food frequency questionnaire that asked about intake of 35 foods (including four drinks). Participants were classified according to the frequency of intake of Western foods and the frequency of intake of traditional Japanese foods. Subgroup analyses were performed using audiometric subtypes of idiopathic sudden deafness. Results Data were obtained for 164 cases and 20 313 controls. An increased risk of sudden deafness was observed among participants who frequently consumed Western foods (OR = 1.82, 95% CI : 1.14‐2.89), and a decreased risk of this condition was observed among participants who frequently consumed Japanese foods (OR = 0.52, 95% CI : 0.33‐0.82). A direct association of sudden deafness with Western food intake was evident for flat-type hearing loss. Conclusions This study suggests that a largely Western diet might be a risk factor for idiopathic sudden deafness, a traditional Japanese diet might be a preventive factor for this condition, or both. These findings are consistent with the hypothesis that vascular factors are an important cause of idiopathic sudden deafness, although the possibility of residual confounding by unmeasured confounders such as socioeconomic status cannot be ruled out.

Sudden deafness sometimes has an identifiable cause, but in most cases the cause is unknown (idiopathic sudden deafness). Vascular impairment has been proposed as an aetiological mechanism for this condition, but it is unclear whether traditional cardiovascular risk factors, such as smoking or alcohol intake, are associated with this condition. We accordingly investigated associations of idiopathic sudden deafness with smoking, alcohol intake and sleep duration in a case-control study. Cases were consecutive patients diagnosed with idiopathic sudden deafness between October 1996 and August 1998 at collaborating hospitals in Japan. Controls were obtained from a nationwide database of pooled controls, with matching for age, gender and residential district. Exposure variables were assessed from a self-administered questionnaire. Subgroup analyses were performed using audiometric subtypes of sudden deafness. Data were obtained for 164 cases and 20,313 controls. Increased risks of idiopathic sudden deafness were observed among participants who consumed two or more units of alcohol per day (OR=1.90, 95% CI=1.12-3.21), and among participants who slept less than seven hours per night (OR=1.61, 95% CI=1.09-2.37). The direct association with alcohol intake was particularly strong for the participants with profound hearing loss. There was little evidence of an association with smoking. This study suggests that alcohol intake and short sleep duration might be risk factors for idiopathic sudden deafness.

Introduction Physical activity is associated with cardiovascular risk in Western populations but evidence from the Chinese population is limited. Methods We examined baseline data on over 500 000 people aged 30–79 years who, during 2004–2008, were recruited into a prospective study from 10 regions in China. Information on physical activity was collected using an interviewer-administered questionnaire that enquired about the frequency, duration and intensity of work-related and leisure activities. Total physical activity (MET-hours/day) was calculated from the time reportedly spent on each activity and the published estimate of energy expenditure per unit time (MET) for that specific activity. Body mass index, blood pressure and capillary glucose were measured. Outcomes of interest included overweight, hypertension, diabetes status (which were all defined using established criteria) and self-reported history of ischaemic heart disease (IHD). Logistic regression analyses were performed to assess the association of physical activity with each outcome. Results Of the 456 118 participants who were free of major chronic diseases other than IHD, the mean age was 51 years and 60% were women. Physical activity was significantly inversely associated with overweight, hypertension, diabetes and IHD, after adjustment for age, sex, region, education, income and smoking status. Comparing the bottom 20% vs the top 20% of physical activity, the adjusted ORs were: 1.25 (95% CI 1.23 to 1.28) for overweight, 1.23 (1.19 to 1.26) for hypertension, 1.72 (1.63 to 1.82) for diabetes and 1.59 (1.46 to 1.73) for IHD (each p Conclusion In Chinese adults, low physical activity is associated with an increased prevalence of overweight, hypertension, diabetes and IHD.

Introduction Raised blood pressure (BP) is a leading cause of premature death in China, but its determinants are not well understood. One likely determinant, adiposity, is increasing rapidly in much of China. We assessed the extent to which differences in BP can be accounted for by differences in body mass index (BMI) and in waist circumference (WC). Methods We examined cross-sectional data from >510 000 adults aged 30–79 recruited from five rural and five urban areas in China. Height, weight, systolic BP and WC were measured for all participants. Means and associations of SBP with age, BMI and WC were estimated in men and women separately. Results The population means (SD) of SBP and BMI in men were 132 (20) mm Hg and 23.4 (3.2) kg/m 2 . Age-adjusted area means of SBP ranged from 126 to 136 mm Hg (F=77 p 2 =0.09), and area means of BMI ranged from 22.0 kg/m 2 to 25.4 kg/m 2 . Overall, and within each area, SBP was approximately linearly associated with BMI: overall +17 mm Hg SBP per +10 kg/m 2 BMI. However, further adjusting SBP for BMI only accounted for an additional 7% of individual variation in SBP, and had little effect on differences between area means of SBP (F=30 p 2 ), mean SBP was higher in rural areas (132 vs 131 mm Hg, p Conclusions SBP is consistently associated with adiposity in individuals, but differences in adiposity do not account for most of the differences in SBP between individuals or between areas.

Introduction Seasonal variation in blood pressure and its association with outdoor air temperature has been reported in several studies. However, large population-based studies are few and data from developing countries such as China are limited. Methods Cross-sectional data from the Kadoorie Biobank Study were used to relate seasonal variation in systolic blood pressure (SBP) to outdoor air temperature in 510 000 Chinese adults aged 30–79 recruited during 2004–2008 at 10 widely separated study sites. Analyses related mean SBP—overall and in subgroups of the population—to mean local air temperature on the day of recruitment. Results SBP was strongly inversely associated with temperature within all 10 areas studied, at least above 5°C, with a mean rise of 5.7 (SE 0.04) mm Hg per 10°C fall in outdoor temperature. The mean difference in SBP between summer (Jun–Aug) and winter (Dec–Feb) was 10 mm Hg, and was more extreme in rural than in urban areas (12 vs 8 mm Hg). The association was slightly stronger in older people, at lower body mass index, and in people taking antihypertensive medications. At low temperature the association was greatly attenuated in participants with central heating in their home. Conclusion SBP is strongly inversely associated with outdoor temperature in Chinese adults, across a range of climatic exposures. Season or temperature and access to central heating should be considered a source of variation in epidemiological studies of blood pressure and in the clinical management of hypertension.

Risk equations based on the Framingham Heart Study (FHS) are used in NZ to predict the 5y risk of incident cardiovascular (CV) events. OBJECTIVE: To establish how well the FHS equations predict first hospitalisation or mortality from CV events in a New Zealand (NZ) population without overt CV disease. METHODS: Observations were taken from a cohort study with 6354 (4638 M +1716 F) participants age 32–74 without known CV disease, taken from the workforce of a nation-wide multi-industry corporation plus a random sample of the Auckland electoral rolls. Prognostic factors were assessed in 1992/93 by a questionnaire plus physiological measurements (BP, cholesterol etc.). Age-specific risk predictions from the FHS were compared with age-specific mortality plus relevant hospital discharges from January 1988 to December 1998 (NZ Health Information Service). RESULTS: The 5y incidence of first hospitalisation for any CV event was 6.4% (male) and 4.4% (female). Table 1 compares observed hospitalised events or mortality with predicted incident events, averaged across 5y age bands. CONCLUSIONS: FHS risk equations accurately predict age-specific incident hospitalized CHD or stroke events or mortality for NZ males age 30–74 but under-estimate MI events. Prediction is less accurate and precise for females. Ratio of observed to predicted events, averaged across 8 × 5y age bands Mean ratio (±SD) Male Female Both CHD 1.03 ± 0.15 0.92 ± 0.35 1.03 ± 0.06 MI 1.24 ± 0.19 1.49 ± 1.19 1.26 ± 0.15 STROKE 0.98 ± 0.40 0.74 ± 0.57 0.94 ± 0.42