Association of haemoglobin levels in the first trimester and at 26-30 weeks with fetal and neonatal outcomes: a secondary analysis of the Global Network for Women's and Children's Health's ASPIRIN Trial.

OBJECTIVE: Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes. DESIGN: ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6+0 -13+6  weeks and 26+0 -30+0  weeks of gestation with fetal and neonatal outcomes. SETTING: Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala. POPULATION: A total of 11 976 pregnant women. METHODS: Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes. MAIN OUTCOME MEASURES: Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g. RESULTS: The mean haemoglobin levels at 6+0 -13+6  weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6+0 -13+6  weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation. CONCLUSIONS: Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6+0 -13+6  weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger. TWEETABLE ABSTRACT: Both lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6-13 weeks and 26-30 weeks of gestation.

The effects of exercise stress testing, diurnal variation and temporal decline on circulating progenitor cells.

Endothelial damage/dysfunction is involved in numerous cardiovascular disease processes. Given that the mature endothelial cells have limited capacity for self regeneration, circulating progenitor cells (CPCs) may modulate the balance between vascular damage and regeneration. The three aims of the present study were 1) to define the influence of exercise treadmill testing (ETT) on peripheral CPC levels; 2) to assess the diurnal variation of CPC counts; and 3) to investigate the rate of temporal decline in CPCs once ex vivo . The dynamics of CPC count changes following an ETT were assessed on consecutive 20 patients referred to our 'rapid-access' chest pain clinic (70% male, age 69.9 +/- 7.8) with venous blood samples taken pre-exercise, immediately post-exercise and at 30 minutes post-exercise. Diurnal variation in CPCs was assessed in 13 stable in-hospital patients (46% male, age 69.1 +/- 7.5 years) with blood samples were taken five times every 6 hours. To investigate the temporal decline, blood samples from 12 patients (58.3% male, age 69.9 +/- 7.9 years) were reprocessed for CPC counts at 4 hours and at 24 hours after sample collection. Plasma levels of von Willebrand factor (vWf) and soluble E-selectin (sE-selectin) were assessed by ELISA. CPCs were enumerated with flow cytometry as CD34+, CD133+, CD45dim events. Exercise led to significant increases in vWF and sE-selectin levels, but no significant influence on CPC counts were observed. Baseline CPC numbers demonstrated a negative correlation with vWf (r=-0.551, p=0.012) and sE-selectin levels (r=-0.494, p=0.027). CPC counts showed a significant diurnal variation, being significantly higher at 12 a.m. compared to 12 p.m. (p=0.046) and 6 p.m. (p=0.023). A 4 hour delay in sample preparation did not affect CPCs counts, but there was a significant decline in CPC recovery when sample processing was delayed by 24 hours (p<0.05). Routine exercise stress testing does not significantly affect CPC counts. Peripheral CPC levels showed a significant diurnal variation. Delays in sample preparation for CPC counts should be avoided as they may influence the accuracy of the test by resulting in a significant decline in CPC recovery. Thus, various factors may affect accuracy of CPC enumeration that may limit their role as a reliable clinical marker and biomarker of endothelial damage.

Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project.

BACKGROUND: Stroke is a major cause of premature mortality in Britain, but its burden is markedly greater amongst South Asians. Because of the paucity of data in this area, we investigated the magnitude and impact of risk from cardiovascular comorbidities on survival amongst South Asian stroke patients. METHODS: We reviewed hospital case records of consecutive first in life time ischaemic stroke patients [self reported ethnicity and International Classification of Disease (ICD) 10th revision, codes 430-438] admitted to an inner city hospital in the UK between 1997 and 2001. In-hospital mortality data and CVD risk factors were analysed. Five-year mortality data was obtained from the National Health Tracing Services. RESULTS: Of 1474 ischaemic stroke patients, 242 (16%) were South Asian of whom, 143 (59.1%) were male. The prevalence of hypertension was 70.2%, followed by diabetes 56.2%, hyperlipidaemia 7% and myocardial infarction 10.3%. At 5 years follow-up, 40.5% had died. Cumulative event-free survival at 5 years was significantly poorer in patients with diabetes (log-rank test, p=0.009). On Cox regression analysis, incorporating age, gender and other CVD risk factors, diabetes mellitus was an independent predictor of mortality odds ratio=1.65 (1.02-2.6, p=0.039). Hypertension and dyslipidaemia did not discriminate survival amongst South Asian patients. CONCLUSION: Stroke mortality in South Asians is associated with presence of diabetes mellitus. This highlights the significance of early and intensive CVD risk modification strategies in ethnic minorities particularly in patients with diabetes. Further research is warranted in South Asians to examine the underlying basis and related pathophysiological abnormalities.

Should oral glucose tolerance testing be mandatory following acute myocardial infarction?

A high prevalence of newly detected diabetes mellitus (DM) and impaired glucose tolerance (IGT) has been reported in patients with acute myocardial infarction (AMI) and no previous diagnosis of DM. However, the prevalence of newly detected DM is grossly underestimated by using fasting plasma glucose (FPG). We determined the prevalence of DM and IGT in patients post-AMI from our local mixed ethnicity population, and evaluated the usefulness of oral glucose tolerance testing in such patients. All non-diabetic subjects admitted with AMI underwent a standardised oral glucose tolerance test (OGTT) with 75 g glucose load predischarge in our institution. Fasting and 2-h postchallenge plasma glucose levels were recorded, in addition to admission plasma glucose, serum cholesterol, triglycerides, HDL cholesterol and haemoglobin A1(C)levels. We studied 61 patients [38 (62%) male; mean (SD) age, 64 (12.5) years], of whom 70% were white European and 30% South Asians. Mean (SD) plasma glucose concentration on admission was 6.9 (1.7; range, 5.8-8.1) mmol/l. Newly diagnosed DM and IGT were detected in 31% (95% CI 10-52) and 33% (95% CI 12-53) of patients respectively. Of those with newly detected diabetes only 32% (95% CI 0-69) had FPG > 6.1 mmol/l. The 12 month major adverse cardiac event rate was 4.5%, 15% and 32% in those with normal glucose tolerance, IGT and DM respectively. Previously undiagnosed DM and IGT in patients with AMI is common. The false reassurance of a normal FPG denies a significant proportion of undiagnosed diabetics the chance of early treatment. The importance of OGTT in the diagnostic work up of this vulnerable high-risk group cannot be over-emphasised.

Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan.

AIMS: To study the within ethnic subgroup variations in diabetes and central obesity among South Asians. METHODS: Data from 9442 individuals age > or = 15 years from the National Health Survey of Pakistan (NHSP) (1990-1994) were analysed. Diabetes was defined as non-fasting blood glucose > or = 7.8 mmol/l, or known history of diabetes. Central obesity was measured at the waist circumference. Distinct ethnic subgroups Muhajir, Punjabi, Sindhi, Pashtun, and Baluchi were defined by mother tongue. RESULTS: The age-standardized prevalence of diabetes varied among ethnic subgroups (P = 0.002), being highest among the Muhajirs (men 5.7%, women 7.9%), then Punjabis (men 4.6%, women 7.2%), Sindhis (men 5.1%, women 4.8%), Pashtuns (men 3.0%, women 3.8%), and lowest among the Baluchis (men 2.9%, women 2.6%). While diabetes was more prevalent in urban vs. rural dwellers [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.24, 1.82], this difference was no longer significant after adjusting for central obesity (OR 1.15, 95% CI 0.95, 1.42). However, the ethnic differences persisted after adjusting for major sociodemographic risk factors (unadjusted OR for Pashtun vs. Punjabi 0.59, 95% CI 0.42, 0.84, adjusted OR 0.54, 95% CI 0.37, 0.78). Ethnic variation was also observed in central obesity, which varied with gender, and did not necessarily track with ethnic differences in diabetes. CONCLUSIONS: Unmeasured environmental or genetic factors account for ethnic variations in diabetes and central obesity, and deserve further study.

Breast cancer and risk factors in an African population: a case referent study.

Numerous studies have investigated different aspects of breast cancer including the known risk factors in the Western world. In sub-Saharan Africa breast cancer in women despite being a public health problem has not received attention from national health providers. This case-referent study investigated the association between a number of risk factors and breast cancer in Tanzania. There was a strong evidence of breast cancer risk increasing with parity chi 2 = 10.6; p = 0.001. However lactation did not show a significant protective effect against breast cancer (OR = 0.6, p = 0.5). Other factors investigated included age at menarche, age at first sex, marital status, age at menopause and duration of menstruation. Statistical analysis revealed that these factors were not significantly associated with breast cancer in these Tanzanian women. The influence of these results are discussed in terms of possible intervention strategies.

TNM classification and breast cancer in an African population: a descriptive study.

OBJECTIVE: To determine the stage of female breast cancer in an African population at presentation by using the TNM classification of the International Union Contra Cancer (UICC). DESIGN: A descriptive study. SETTING: Hospital based investigation. SUBJECTS: All 50 female patients with breast carcinoma admitted between March and October 1996 to the surgery wards at the Muhimbili Medical Centre, the largest referral centre in Tanzania were studied for the stage of the disease at presentation. RESULTS: A total of 50 cases were recruited in this study. There was not a single case in Stage I. In Stage II there was only one case (T2 N0, n = 1). There were seven cases in Stage IIIA (T3 N0, n = 5; T1 N2, n = 1; T3 N2, n = 1) while in Stage IIIB there were 37 cases (T3 N3, n = 1; T4 N1, n = 27; T4 N2, n = 9). There were five cases in Stage IV (M1, n = 5). Histological analysis revealed all tumours were infiltrating duct carcinoma. Metastatic disease (Stage IV) was observed only in patients aged above 50 years. CONCLUSIONS: Breast cancer presents predominantly as a locally advanced disease, with virtual absence of early disease. A majority of the patients are premenopausal in an African population. Self breast examination (SBE) including other strategies suggested earlier are recommended to aid in early detection of breast cancer.