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Secondary treatment improves outcomes
Mortality following acute myocardial infarction in an English health district improved significantly over a five year period, corresponding directly with an increase in secondary treatment of cholesterol levels.
Each year, around 300 000 people in England suffer an acute myocardial infarct and coronary heart disease in general claims over 110 000 lives—figures the United Kingdom government is aiming to reduce with the recent publication (in 2000) of the National Service Framework for coronary heart disease.
In the five year period before that report (and its recommendations for increased secondary treatment) was published, the authors found that mortality at 30 days after myocardial infarct showed an annual reduction of 9%. Almost three quarters of one year survivors had their serum lipids measured in 1995, with the proportion rising year on year to 88% in 1999. The recommended target for total cholesterol (<5 mmom/l) was achieved by 27% of men and 23% of women admitted in 1995 and rose to 74% and 53% respectively for those admitted in 1999.
While demonstrating the advantages of secondary treatment in general and cholesterol lowering in particular following myocardial infarction, the data highlight worrying sex differences: men were 1.60-fold more likely than women to have their cholesterol levels tested after myocardial infarction, and women had a higher incidence of mortality, both at 30 days and one year after infarct. This suggests that women receive less rigorous care than men after myocardial infarction and naturally leads to questions regarding why this happens and how it can be prevented in future. (
Childbirth blights sight in central india
A significant association was found between childbearing and risk of sight impairing cataract in central India. Having more than three babies doubled the risk, with each additional birth increasing the risk by 20%. (
Surgical staff in the Chattisgarth Eye Hospital in the Raipur district of Madhya Pradesh in Central India noticed that comparatively young women represented a disproportionate amount of patients receiving surgery for sight impairing cataract. A case-control study was organised in conjunction with colleagues at the Institute of Ophthalmology in the UK and showed an odds ratio of 1.2 for cataract after one to three births, rising to 1.7 for four births and further to 4.1 for more than six births. The birth effect was independent of age, socioeconomic status, body mass index, and repeated severe dehydration, all putative risk factors for cataract.
The challenge now is to identify the cataract specific risk factors that mothers may be exposed to during pregnancy and childbirth, particularly under poor socioeconomic conditions.
No smog without ire
Children living in areas of high pollution are at risk of developing vitamin D deficiency rickets and should be offered vitamin D supplements. (
The most important source of vitamin D is that produced in the skin after exposure to ultraviolet B sunlight, and there is increasing concern that smog created by industrial and vehicular emissions absorbs ultraviolet B photons, thus reducing the cutaneous vitamin D synthesis.
Researchers recruited a total of 57 children from Delhi, India, who lived in two areas of the city with disparate pollution levels, and hypothesised that serum total 25-hydroxycholecalciferol (25(OH)D)—a reliable measure of vitamin D status—would be lower in those from the heavily polluted area. They were right: mean 25(OH)D of children in the more polluted area was 12.4 (7) ng/ml, compared with 27.1 (7) ng/ml in children in the less polluted area. The authors also measured the amount of ultraviolet B sunlight to reach the ground in both areas and found that significantly more did so in the less polluted area.
The findings swell unease about the public health effects of our increasingly polluted planet, and confirm the importance of pollution on reducing effective ultraviolet B levels, even in traditionally sunny countries at low latitudes (see fig 1). The authors recommend the introduction of a vitamin D supplement programme and are currently evaluating the potential effectiveness of such a programme through a large randomised trial.
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