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Increasing evidence suggests that preterm birth affects later lung function. We systematically reviewed the literature to determine whether percentage predicted forced expiratory volume in 1 s (%FEV1) is lower in later life in preterm-born subjects, with or without bronchopulmonary dysplasia (BPD), compared with term-born controls. Studies reporting %FEV1, with or without a term-born control group, in later life for preterm-born subjects (<37 weeks gestation) were extracted from eight databases. Data were analysed using Review Manager and STATA. The quality of the studies was assessed. From 8839 titles, 1124 full articles were screened and 59 were included: 28 studied preterm-born children without BPD, 24 with BPD28 (supplemental oxygen dependency at 28 days), 15 with BPD36 (supplemental oxygen dependency 36 weeks postmenstrual age) and 34 born preterm. For the preterm-born group without BPD and for the BPD28 and BPD36 groups the mean differences (and 95% CIs) for %FEV1 compared with term-born controls were -7.2% (-8.7% to -5.6%), -16.2% (-19.9% to -12.4%) and -18.9% (-21.1% to -16.7%), respectively. Pooling all data on preterm-born subjects whether or not there was a control group gave a pooled %FEV1 estimate of 91.0% (88.8% to 93.1%) for the preterm-born cohort without BPD, 83.7% (80.2% to 87.2%) for BPD28 and 79.1% (76.9% to 81.3%) for BPD36. Interestingly, %FEV1 for BPD28 has improved over the years. %FEV1 is decreased in preterm-born survivors, even those who do not develop BPD. %FEV1 of survivors of BPD28 has improved over recent years. Long-term respiratory follow-up of preterm-born survivors is required as they may be at risk of developing chronic obstructive pulmonary disease.

Aims Determine the prevalence and severity of diabetic retinopathy (DR) and risk factors in a large community based screening programme, in order to accurately estimate the future burden of this specific and debilitating complication of diabetes. Methods A cross-sectional analysis of 91 393 persons with diabetes, 5003 type 1 diabetes and 86 390 type 2 diabetes, at their first screening by the community based National Diabetic Retinopathy Screening Service for Wales from 2005 to 2009. Image capture used 2×45° digital images per eye following mydriasis, classified by qualified retinal graders with final grading based on the worst eye. Results The prevalence of any DR and sight-threatening DR in those with type 1 diabetes was 56.0% and 11.2%, respectively, and in type 2 diabetes was 30.3% and 2.9%, respectively. The presence of DR, non-sight-threatening and sight-threatening, was strongly associated with increasing duration of diabetes for either type 1 or type 2 diabetes and also associated with insulin therapy in those with type 2 diabetes. Conclusions Prevalence of DR within the largest reported community-based, quality assured, DR screening programme, was higher in persons with type 1 diabetes; however, the major burden is represented by type 2 diabetes which is 94% of the screened population.

BackgroundRates of preterm birth have increased in most industrialised countries but data on later lung function of late preterm births are limited. A study was undertaken to compare lung function at 8–9 and 14–17 years in children born late preterm (33–34 and 35–36 weeks gestation) with children of similar age born at term (≥37 weeks gestation). Children born at 25–32 weeks gestation were also compared with children born at term.MethodsAll births from the Avon Longitudinal Study of Parents and Children (n=14 049) who had lung spirometry at 8–9 years of age (n=6705) and/or 14–17 years of age (n=4508) were divided into four gestation groups.ResultsAt 8–9 years of age, all spirometry measures were lower in the 33–34-week gestation group than in controls born at term but were similar to the spirometry decrements observed in the 25–32-week gestation group. The 35–36-week gestation group and term group had similar values. In the late preterm group, at 14–17 years of age forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were not significantly different from the term group but FEV1/FVC and forced expiratory flow at 25–75% FVC (FEF25–75%) remained significantly lower than term controls. Children requiring mechanical ventilation in infancy at 25–32 and 33–34 weeks gestation had in general lower airway function (FEV1 and FEF25–75) at both ages than those not ventilated in infancy.ConclusionsChildren born at 33–34 weeks gestation have significantly lower lung function values at 8–9 years of age, similar to decrements observed in the 25–32-week group, although some improvements were noted by 14–17 years of age.

ObjectiveDoes TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)?DesignProspective comparative longitudinal study.SettingCommunity.PatientsChildren <6 years old.InterventionsThe number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases.Main outcome measuresLikelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD.ResultsAny bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%.ConclusionsThese data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

Few studies have investigated childhood respiratory outcomes of intrauterine growth retardation (IUGR), and it is unclear if catch-up growth in these children influences lung function. We determined if lung function differed in 8- to 9-year-old children born at term with or without growth retardation, and, in the growth-retarded group, if lung function differed between those who did and those who did not show weight catch up. Caucasian singleton births of 37 weeks or longer gestation from the Avon Longitudinal Study of Parents and Children (n = 14,062) who had lung spirometry at 8-9 years of age were included (n = 5,770). Infants with gestation-appropriate birthweight (n = 3,462) had significantly better lung function at 8-9 years of age than those with IUGR (i.e., birthweight <10th centile [n = 576] [SD differences and confidence intervals adjusted for sex, gestation, maternal smoking during pregnancy, and social class: FEV(1), -0.198 (-0.294 to -0.102), FVC, -0.131 (-0.227 to -0.036), forced midexpiratory flow between 25 and 75% of vital capacity -0.149 (-0.246 to -0.053)]). Both groups had similar respiratory symptoms. All spirometry measurements were higher in children with IUGR who had weight catch-up growth (n = 430) than in those without (n = 146), although the differences were not statistically significant. Both groups remained significantly lower than control subjects. Growth-retarded asymmetric and symmetric children had similar lung function. IUGR is associated with poorer lung function at 8-9 years of age compared with control children. Although the differences were not statistically significant, spirometry was higher in children who showed weight catch-up growth, but remained significantly lower than the control children.

Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 and it is estimated that approximately 50% of the fall was due to improved treatment uptake. Marked socio-economic inequalities in CHD mortality in the United Kingdom (UK) remain, with higher age-adjusted rates in more deprived groups. Inequalities in the persistence of medication for primary and secondary prevention of CHD may contribute to the observed social gradient and we investigated this possibility in the population of Wales (UK). An electronic cohort of individuals aged over 20 (n = 1,199,342) in Wales (UK) was formed using linked data from primary and secondary care and followed for six years (2004-2010). We identified indications for medication (statins, aspirin, ACE inhibitors, clopidogrel) recommended in UK National Institute for Clinical Excellence (NICE) guidance for CHD (high risk, stable angina, stable angina plus diabetes, unstable angina, and myocardial infarction) and measured the persistence of indicated medication (time from initiation to discontinuation) across quintiles of the Welsh Index of Multiple Deprivation, an area-based measure of socio-economic inequality, using Cox regression frailty models. In models adjusted for demographic factors, CHD risk and comorbidities across 15 comparisons for persistence of the medications, none favoured the least deprived quintile, two favoured the most deprived quintile and 13 showed no significant differences. During our study period (2004-2010) we found no significant evidence of socio-economic inequality in the persistence of recommended medication for primary and secondary prevention of CHD.

Interaction between arterial stiffness and hypertension plays an important role in the development of cardiovascular disease. Accordingly, assessment of arterial stiffness may provide a tool for estimating cardiovascular risk and monitoring therapy in hypertensive patients. Radiofrequency-based vascular ultrasound allows accurate noninvasive assessment of local mechanical properties of large arteries, but for its use in clinical practice, reference values according to age and sex are mandatory for each vascular site. To provide reference values for common carotid artery stiffness as assessed by an echo-tracking imaging system Hitachi-Aloka, we pooled measurements collected in 1847 healthy subjects aged 3–74 years (1008 males and 839 females) recruited in 14 European centers in the E-tracking International Collaboration (ETIC). Statistical models were developed to describe relationships of different stiffness indices with age and to calculate median values and Z-scores corresponding to ± 1 and ± 2 standard deviations. In our apparently healthy population, age accounted for 53% of variability in the elastic modulus (epsilon), 39% in arterial compliance, 47% in stiffness index (β), and 56% in local pulse wave velocity; on average, blood pressure accounted for a further 7.5% of variability. Dependence on age was not linear; changes in mean values increased at older ages, especially for epsilon and β. There was an interaction between age and gender for arterial compliance, which was higher in males. We present nomograms and a software that can be used for the automated calculation of Z-scores for local carotid stiffness in individual patients. These tools can be used to establish prognostic indicators or surrogate targets for treatment monitoring.

Correspondence to Professor Jonathan Rhodes, Cellular and molecular physiology, University of Liverpool Institute of Translational Medicine, Liverpool L69 3BX, UK; rhodesjm@liverpool.ac.uk Dear Editors, We read with interest the review by Dr Kohlmeier in which he reported a correlation between COVID-19 mortality among African-Americans across the USA and northern latitude.1 We previously reported a north–south gradient in global COVID-19 mortality but were conscious that lack of ultraviolet exposure and consequent vitamin D insufficiency was not the only possible explanation.2 We have now investigated the relationships between latitude, age of population, population density and pollution with COVID-19 mortality. Data by country for population %≥65 years, population density and air pollution (particles of matter <2.5 um diameter µg/m3) were obtained from public sources.4–6 Latitude was entered for each country’s capital city. Table 1 Associations between COVID-19 mortality by country, latitude and % of population ≥65 years Variable Regression coefficient SE P value % of variation explained Effect size (95% CI)* Univariate models   Latitude 0.1074 0.0142 <0.0005 33.1 11.3% (8.3% to 14.5%)   %≥65 0.1766 0.0199 <0.0005 40.4 19.3% (14.8% to 24.1%) Multivariate model   Latitude 0.0428 0.0196 0.031 43.0 4.4% (0.4% to 8.5%)   %≥65 0.1281 0.0291 <0.0005 13.7% (7.4% to 20.3%) *The effect size is, for latitude, the percentage increase in mortality from one location, situated at least 28° north, to another location 1° further north and, for %≥65, the percentage increase in mortality for each one % increase in %≥65.

Objectives The influence of neighbourhood deprivation on the risk of harmful alcohol consumption, measured by the separate categories of excess consumption and binge drinking, has not been studied. The study objective was to investigate the effect of neighbourhood deprivation with age, gender and socioeconomic status (SES) on (1) excess alcohol consumption and (2) binge drinking, in a representative population survey. Design Cross-sectional study: multilevel analysis. Setting Wales, UK, adult population ∼2.2 million. Participants 58 282 respondents aged 18 years and over to four successive annual Welsh Health Surveys (2003/2004–2007), nested within 32 692 households, 1839 census lower super output areas and the 22 unitary authority areas in Wales. Primary outcome measure Maximal daily alcohol consumption during the past week was categorised using the UK Department of Health definition of ‘none/never drinks’, ‘within guidelines’, ‘excess consumption but less than binge’ and ‘binge’. The data were analysed using continuation ratio ordinal multilevel models with multiple imputation for missing covariates. Results Respondents in the most deprived neighbourhoods were more likely to binge drink than in the least deprived (adjusted estimates: 17.5% vs 10.6%; difference=6.9%, 95% CI 6.0 to 7.8), but were less likely to report excess consumption (17.6% vs 21.3%; difference=3.7%, 95% CI 2.6 to 4.8). The effect of deprivation varied significantly with age and gender, but not with SES. Younger men in deprived neighbourhoods were most likely to binge drink. Men aged 35–64 showed the steepest increase in binge drinking in deprived neighbourhoods, but men aged 18–24 showed a smaller increase with deprivation. Conclusions This large-scale population study is the first to show that neighbourhood deprivation acts differentially on the risk of binge drinking between men and women at different age groups. Understanding the socioeconomic patterns of harmful alcohol consumption is important for public health policy development.

Health status in childhood is correlated with educational outcomes. Emergency hospital admissions during childhood are common but it is not known how these unplanned breaks from schooling impact on education outcomes. We hypothesised that children who had emergency hospital admissions had an increased risk of lower educational attainment, in addition to the increased risks associated with other health, social and school factors. This record-linked electronic birth cohort, included children born in Wales between 1 January 1998 and 31 August 2001. We fitted multilevel logistic regression models grouped by schools, to determine whether emergency hospital inpatient admission before age 7 years was associated with the educational outcome of not attaining the expected level in a teacher-based assessment at age 7 years (KS1). We adjusted for pregnancy, perinatal, socio-economic, neighbourhood, pupil mobility and school-level factors. The cohort comprised 64 934 children. Overall, 4680 (7.2%) did not attain the expected educational level. Emergency admission to hospital was associated with poor educational attainment (OR 1.12 95% Credible Interval (CI) 1.05, 1.20 for all causes during childhood, OR 1.19 95%CI 1.07, 1.32 for injuries and external causes and OR 1.31 95%CI 1.04, 1.22 for admissions during infancy), after adjusting for known determinants of education outcomes such as extreme prematurity, being small for gestational age and socio-economic indicators, such as eligibility for free school meals. Emergency inpatient hospital admission during childhood, particularly during infancy or for injuries and external causes was associated with an increased risk of lower education attainment at age 7 years, in addition to the effects of pregnancy factors (gestational age, birthweight) and social deprivation. These findings support the need for injury prevention measures and additional support in school for affected children to help them to achieve their potential.