H R Anderson

Incidence and prognosis of asthma and wheezing illness from early childhood to age 33 in a national British cohort

Abstract Objective: To describe the incidence and prognosis of wheezing illness from birth to age 33 and the relation of incidence to perinatal, medical, social, environmental, and lifestyle factors. Design: Prospective longitudinal study. Setting: England, Scotland, and Wales. Subjects: 18 559 people born on 3-9 March 1958. 5801 (31%) contributed information at ages 7, 11, 16, 23, and 33 years. Attrition bias was evaluated using information on 14 571 (79%) subjects. Main outcome measure: History of asthma, wheezy bronchitis, or wheezing obtained from interview with subjects parents at ages 7, 11, and 16 and reported at interview by subjects at ages 23 and 33. Results: The cumulative incidence of wheezing illness was 18% by age 7, 24% by age 16, and 43% by age 33. Incidence during childhood was strongly and independently associated with pneumonia, hay fever, and eczema. There were weaker independent associations with male sex, third trimester antepartum haemorrhage, whooping cough, recurrent abdominal pain, and migraine. Incidence from age 17 to 33 was associated strongly with active cigarette smoking and a history of hay fever. There were weaker independent associations with female sex, maternal albuminuria during pregnancy, and histories of eczema and migraine. Maternal smoking during pregnancy was weakly and inconsistently related to childhood wheezing but was a stronger and significant independent predictor of incidence after age 16. Among 880 subjects who developed asthma or wheezy bronchitis from birth to age 7, 50% had attacks in the previous year at age 7; 18% at 11, 10% at 16, 10% at 23, and 27% at 33. Relapse at 33 after prolonged remission of childhood wheezing was more common among current smokers and atopic subjects. Conclusion: Atopy and active cigarette smoking are major influences on the incidence and recurrence of wheezing during adulthood. Key messages Incidence of wheezing illness at all ages was strongly and consistently related to a history of hay fever or eczema (atopy). Associations with maternal smoking during pregnancy, abdominal pain, and migraine were largely confined to those without atopy Active smoking was a powerful and potentially avoidable risk factor for wheeze starting in adult life among both atopic and non-atopic subjects A quarter of the children with a history of asthma or wheezy bronchitis by age 7 reported wheeze in the past year at age 33 Recurrence of wheezing after prolonged remis- sion during late adolescence was strongly associ- ated with atopy and cigarette smoking.

EFFECTS ON BIRTH-WEIGHT OF SMOKING, ALCOHOL, CAFFEINE, SOCIOECONOMIC-FACTORS, AND PSYCHOSOCIAL STRESS

OBJECTIVE--To investigate the effects of smoking, alcohol, and caffeine consumption and socio-economic factors and psychosocial stress on birth weight. DESIGN--Prospective population study. SETTING--District general hospital in inner London. PARTICIPANTS--A consecutive series of 1860 white women booking for delivery were approached. 136 Refused and 211 failed to complete the study for other reasons (moved, abortion, subsequent refusal), leaving a sample of 1513. Women who spoke no English, booked after 24 weeks, had insulin dependent diabetes, or had a multiple pregnancy were excluded. MEASUREMENTS--Data were obtained by research interviewers at booking (general health questionnaire, modified Paykels interview, and Eysenck personality questionnaire) and at 17, 28, and 36 weeks gestation and from the structured antenatal and obstetric record. Variables assessed included smoking, alcohol consumption, caffeine consumption, and over 40 indicators of socio-economic state and psychosocial stress, including social class, tenure of accommodations, education, employment, income, anxiety and depression, stressful life events, social stress, social support, personality, and attitudes to pregnancy. Birth weight was corrected for gestation and adjusted for maternal height, parity, and babys sex. MAIN RESULTS--Smoking was the most important single factor (5% reduction in corrected birth weight). Passive smoking was not significant (0.5% reduction). After smoking was controlled for, alcohol had an effect only in smokers and the effects of caffeine became non-significant. Only four of the socioeconomic and stress factors significantly reduced birth weight and these effects became non-significant after smoking was controlled for. CONCLUSIONS--Social and psychological factors have little or no direct effect on birth weight corrected for gestational age (fetal growth), and the main environmental cause of its variation in this population was smoking.

Preterm delivery: effects of socioeconomic factors, psychological stress, smoking, alcohol, and caffeine

Abstract Objective: To examine the relation between preterm birth and socioeconomic and psychological factors, smoking, and alcohol and caffeine consumption. Design: Prospective study of outcome of pregnancy. Setting: District general hospital in inner London. Participants: 1860 consecutive white women booking for delivery; 1513 women studied after exclusion because of multiple pregnancy and diabetes, refusals, and loss to follow up. Measurements: Gestational age was determined from ultrasound and maternal dates; preterm birth was defined as less than 37 completed weeks. Independent variables included smoking, alcohol and caffeine consumption, and a range of indicators of socioeconomic status and psychological stress. Main results: Unifactorial analyses showed that lower social class, less education, single marital status, low income, trouble with “nerves” and depression, help from professional agencies, and little contact with neighbours were all significantly associated with an increased risk of preterm birth. There were no apparent effects of smoking, alcohol, or caffeine on the length of gestation overall, although there was an association between smoking and delivery before 32 weeks. Cluster analysis indicated three subgroups of women delivering preterm: two predominantly of low social status and a third of older women with higher social status who did not smoke. Mean gestational age was highest in the third group. Conclusions: Adverse social circumstances are associated with preterm birth but smoking is not, apart from an association with very early births. This runs counter to findings for fetal growth (birth weight for gestational age) in this study, where a strong effect of smoking on fetal growth was observed but there was no evidence for any association with psychosocial factors.

Air pollution and daily mortality in London: 1987-92.

Abstract Objective: To investigate whether outdoor air pollution levels in London influence daily mortality. Design: Poisson regression analysis of daily counts of deaths, with adjustment for effects of secular trend, seasonal and other cyclical factors, day of the week, holidays, influenza epidemic, temperature, humidity, and autocorrelation, from April 1987 to March 1992. Pollution variables were particles (black smoke), sulphur dioxide, ozone, and nitrogen dioxide, lagged 0-3 days. Setting: Greater London. Outcome measures: Relative risk of death from all causes (excluding accidents), respiratory disease, and cardiovascular disease. Results: Ozone levels (same day) were associated with a significant increase in all cause, cardiovascular, and respiratory mortality; the effects were greater in the warm season (April to September) and were independent of the effects of other pollutants. In the warm season an increase of the eight hour ozone concentration from the 10th to the 90th centile of the seasonal range (7-36 ppb) was associated with an increase of 3.5% (95% confidence interval 1.7 to 5.3), 3.6% (1.04 to 6.1), and 5.4% (0.4 to 10.7) in all cause, cardiovascular, and respiratory mortality respectively. Black smoke concentrations on the previous day were significantly associated with all cause mortality, and this effect was also greater in the warm season and was independent of the effects of other pollutants. For black smoke an increase from the 10th to 90th centile in the warm season (7-19 µg/m3) was associated with an increase of 2.5% (0.9 to 4.1) in all cause mortality. Significant but smaller and less consistent effects were also observed for nitrogen dioxide and sulphur dioxide. Conclusion: Daily variations in air pollution within the range currently occurring in London may have an adverse effect on daily mortality. Key messages Evidence from other countries suggests that similar levels of pollution may be associated with short term health effects This study suggests that air pollution due to particles and ozone may be associated with increased daily mortality in London The evidence is less convincing for nitrogen dioxide and sulphur dioxide It would be prudent to assume that these associations are causal and to reduce air pollution levels with the help of appropriate abate- ment policies

Daily time series for cardiovascular hospital admissions and previous day's air pollution in London, UK.

OBJECTIVE: To test for a significant association between air pollution and emergency hospital admissions for circulatory diseases (international classification of diseases-9 390-459) in London, England, that would be consistent with a causal effect of pollution on the previous day. METHODS: Long term concurrent trends, temperature, humidity, day of the week, influenza epidemic of 1989, and cyclical covariations with periodicity > 20 days in daily measures of pollution and admissions for 1987-94 were allowed for. RESULTS: There were 373556 admissions. No association was found between O3 and circulatory diseases. Four other pollutants were associated with acute myocardial infarction and circulatory diseases combined. P values and attributable cases (95% confidence intervals) for acute myocardial infarction were: black smoke P = 0.003, 2.5% (0.8% to 4.3%); NO2 P = 0.002, 2.7% (0.8% to 4.6%); CO P = 0.001, 2.1% (0.7% to 3.5%); and SO2 P = 0.0006, 1.7% (0.7% to 2.6%). There were also associations between black smoke and angina (P = 0.02), NO2 and arrhythmia (P = 0.04), and CO and other circulatory diseases (P = 0.004), but none with heart failure. Acute myocardial infarction was the only diagnosis for which there were significant associations with and without adjustment for cyclical terms. The associations with acute myocardial infarction were significant only in the cool season. CONCLUSION: Population data were consistent with 1 in 50 heart attacks currently presenting at London hospitals being triggered by outdoor air pollution. Further research is now needed to investigate whether background concentrations of black smoke, NO2, CO, and SO2 are a preventable cause of myocardial infarction. These results, if applied to all myocardial infarctions in the United Kingdom, indicate a potential saving of 6000 heart attacks a year.

Randomised controlled trial of effects of coordinating care for terminally ill cancer patients.

OBJECTIVES--To measure effects on terminally ill cancer patients and their families of coordinating the services available within the NHS and from local authorities and the voluntary sector. DESIGN--Randomised controlled trial. SETTING--Inner London health district. PATIENTS--Cancer patients were routinely notified from 1987 to 1990. 554 patients expected to survive less than one year entered the trial and were randomly allocated to a coordination or a control group. INTERVENTION--All patients received routinely available services. Coordination group patients received the assistance of two nurse coordinators, whose role was to ensure that patients received appropriate and well coordinated services, tailored to their individual needs and circumstances. MAIN OUTCOME MEASURES--Patients and carers were interviewed at home on entry to the trial and at intervals until death. Interviews after bereavement were also conducted. Outcome measures included the presence and severity of physical symptoms, psychiatric morbidity, use of and satisfaction with services, and carers problems. Results from the baseline interview, the interview closest to death, and the interview after bereavement were analysed. RESULTS--Few differences between groups were significant. Coordination group patients were less likely to suffer from vomiting, were more likely to report effective treatment for it, and less likely to be concerned about having an itchy skin. Their carers were more likely to report that in the last week of life the patient had had a cough and had had effective treatment for constipation, and they were less likely to rate the patients difficulty swallowing as severe or to report effective treatment for anxiety. Coordination group patients were more likely to have seen a chiropodist and their carers were more likely to contact a specialist nurse in a night time emergency. These carers were less likely to feel angry about the death of the patient. CONCLUSIONS--This coordinating service made little difference to patient or family outcomes, perhaps because the service did not have a budget with which it could obtain services or because the professional skills of the nurse-coordinators may have conflicted with the requirements of the coordinating role.

Air Pollution Pollens, and Daily Admissions for Asthma in London 1987-92

BACKGROUND A study was undertaken to investigate the relationship between daily hospital admissions for asthma and air pollution in London in 1987–92 and the possible confounding and modifying effects of airborne pollen. METHODS For all ages together and the age groups 0–14, 15–64 and 65+ years, Poisson regression was used to estimate the relative risk of daily asthma admissions associated with changes in ozone, sulphur dioxide, nitrogen dioxide and particles (black smoke), controlling for time trends, seasonal factors, calendar effects, influenza epidemics, temperature, humidity, and autocorrelation. Independent effects of individual pollutants and interactions with aeroallergens were explored using two pollutant models and models including pollen counts (grass, oak and birch). RESULTS In all-year analyses ozone was significantly associated with admissions in the 15–64 age group (10 ppb eight hour ozone, 3.93% increase), nitrogen dioxide in the 0–14 and 65+ age groups (10 ppb 24u2009hour nitrogen dioxide, 1.25% and 2.96%, respectively), sulphur dioxide in the 0–14 age group (10u2009μg/m3 24u2009hour sulphur dioxide, 1.64%), and black smoke in the 65+ age group (10u2009μg/m3 black smoke, 5.60%). Significant seasonal differences were observed for ozone in the 0–14 and 15–64 age groups, and in the 0–14 age group there were negative associations with ozone in the cool season. In general, cumulative lags of up to three days tended to show stronger and more significant effects than single day lags. In two-pollutant models these associations were most robust for ozone and least for nitrogen dioxide. There was no evidence that the associations with air pollutants were due to confounding by any of the pollens, and little evidence of an interaction between pollens and pollution except for synergism of sulphur dioxide and grass pollen in children (p<0.01). CONCLUSIONS Ozone, sulphur dioxide, nitrogen dioxide, and particles were all found to have significant associations with daily hospital admissions for asthma, but there was a lack of consistency across the age groups in the specific pollutant. These associations were not explained by confounding by airborne pollens nor was there convincing evidence that the effects of air pollutants and airborne pollens interact in causing hospital admissions for asthma.

Effects of air pollution on daily hospital admissions for respiratory disease in London between 1987-88 and 1991-92.

STUDY OBJECTIVE: To investigate whether air pollution levels in London have short term effects on hospital admissions for respiratory disease. DESIGN: Poisson regression analysis of daily counts of hospital admissions, adjusting for effects of trend, seasonal and other cyclical factors, day of the week, holidays, influenza epidemic, temperature, humidity, and autocorrelation. Pollution variables were particulates (black smoke: BS), sulphur dioxide (SO2), ozone (O3), and nitrogen dioxide (NO2), lagged 0-3 days. SETTING AND PATIENTS: All immediate admissions for respiratory disease (ICD 460-519) to hospitals in London health districts in the five years April 1987 to February 1992 for all ages and the 0-14, 15-64, and 65+ age groups. MAIN RESULTS: O3 (lagged one day) was significantly associated with an increase in daily admissions among all age groups, except the 0-14 group, and this effect was stronger in the warm season (April-September). In this season, the relative risks of admission associated with an increase in 8 hour O3 levels of 29 ppb (10th to 90th centile) were 1.0483 (95% CI 1.0246, 1.0726), 1.0294 (0.9930,1.0672), 1.0751 (1.0354,1.1163), and 1.0616 (1.0243,1.1003) for all ages and age groups 0-14, 15-64, and 65+ respectively. Very few significant associations were observed with the other pollutants, though these tended to be positive. Controlling for other pollutants made little difference to the O3 coefficients. There was evidence of a threshold at about 40-60 ppb O3 (maximum hourly or maximum 8 hour). CONCLUSIONS: O3 levels in London have a small but significant effect on hospital admissions for respiratory disease at all ages. The possible role of aerollergen as a confounding factor needs to be examined. Unlike other cities where similar effects have been reported, little or no effect of particulates was observed in London.

Dying from cancer: the views of bereaved family and friends about the experiences of terminally ill patients:

Objective: To investigate current experiences of dying cancer patients and to identify areas where improvements in care are needed. Design: Interviews with principal carers eight weeks after the death of cancer patients who had been routinely notified by hospital staff and had entered a district wide trial of a new service for terminally ill cancer patients. Setting: An inner London health district. Subjects: Eighty carers of cancer patients who died between 1987 and 1989. Results: Anorexia, breathlessness, pain, insomnia and depression were all experienced by over 50% of patients in the last week of life. Twenty per cent of patients in pain were reported to have had no effective treatment. Carers of patients dying at home were significantly more likely to feel that the place of death had been right for the patient (97% versus 53%) than carers of patients dying in hospital. Half (36) of carers were dissatisfied with hospital care: the main reason given was that nurses were too busy to provide adequate care (24). Thirty-nine per cent of carers were dissatisfied with information they received from the hospital and eight had wanted to know more about the timing of death. Twenty-seven per cent of 64 carers who had had contact with the general practitioner during the final illness were dissatisfied with care provided by the GP. Twenty per cent of 56 carers who had had contact with district nurses were dissatisfied because of the lack of continuity of care or because nurses appeared rushed. Twenty-nine per cent had had a home help and 10% had had meals on wheels. Fifty-two per cent of carers needing equipment to help them nurse the patient, and 15% of carers who had needed help during the night, had been unable to obtain such help without difficulty, if at all. Implications: More attention should be paid to ensuring that good symptom control is achieved for all patients. More support from general practitioners, community nursing and social services is needed to enable patients to remain at home when desired. Improvements are needed in the care provided for dying patients on acute wards.

The natural history of asthma in childhood.

The incidence and prognosis of childhood asthma and wheezing illness (AW) was studied using data obtained at ages 7, 11, and 16 from a national cohort of 8806 children born in 1958. By the age of 16, 24.7% were reported to have experienced at least one episode of AW. In 18.3% AW had started before the age of 8, but only 4.2% continued to have symptoms in later childhood. A further 3.6% began to have AW between the ages of 8 and 11, and 2.8% began between the ages of 12 and 16. Of those with AW at age 7, 28.3% had symptoms at 11 and 16.5% at 16; these proportions were about doubled if AW at 7 had been severe. The associations between natural history and a large number of perinatal, social, environmental, and medical factors were examined. Those which predicted the onset of AW after the age of 7 were: male sex of child; mother aged 15-19 at childs birth; history of pneumonia, whooping cough, throat or ear infections or tonsillectomy; eczema, allergic rhinitis; and periodic vomiting or abdominal pain.