Aleksei Baburin

The association between hyperglycaemia on admission and 180-day mortality in acute myocardial infarction patients with and without diabetes.

Aim  To evaluate the association between hyperglycaemia on admission, previously known diabetes and 180‐day mortality in acute myocardial infarction (AMI) patients.

Cancer incidence and cause-specific mortality in male and female physicians: a cohort study in Estonia.

Aims: To evaluate whether the presumed knowledge of physicians about healthier lifestyle decreases their risk of cancer and mortality, a retrospective cohort study of male and female physicians was conducted in Estonia. Methods: The cancer incidence and cause-specifi c mortality of 3,673 physicians (870 M, 2,803 F ) in Estonia was compared with the rates of the general population. Information on cancer cases and deaths in the cohort between 1983 and 1998 was obtained from the Estonian Cancer Registry and the mortality database of Estonia. Results: The standardized incidence ratio (SIR) for all cancers was 1.32 (95% confi dence interval (CI) 1.15-1.48) in women and 0.92 (95% CI 0.73-1.13) in men. Female physicians had an elevated risk for breast cancer (SIR 2.03, 95% CI 1.62-2.51) and myeloid leukaemia (SIR 3.69, 95% CI 1.35-8.02). Male physicians had an excess of skin melanoma (SIR 4.88, 95% CI 1.58-11.38). A large defi cit of lung cancer was observed (SIR 0.24, 95% CI 0.11-0.48). The very low all-cause mortality in the cohort (standardized mortality ratio 0.55, 95% CI 0.50-0.61) was mainly due to large defi cits in deaths from lung cancer, cardiovascular diseases and external causes. The suicide rate in the cohort was lower than in the general population. Conclusions: No health risks were observed in the cohort that could be linked to the occupational exposures of physicians. The pattern of cancer incidence and mortality seen in physicians in Estonia is similar to the pattern seen among professional classes in other countries.

Comparison of management and 30-day mortality of acute myocardial infarction in men versus women in Estonia.

Objective — There is conflicting information about gender differences in clinical features, management and outcome after acute myocardial infarction (AMI). The objective of the study was to compare the baseline characteristics, management and 30-day mortality of AMI in men and women in Estonia. Methods — This study included consecutive unselected patients from the Myocardial Infarction Registry (MIR) in Estonia, who were admitted to a university hospital between January 2001 and February 2002. Logistic regression analysis was used to estimate crude and adjusted odds ratios (OR) with 95 percent confidence intervals (95% CI). Results — The study included 228 men and 167 women.Women were older than men (73.49 ± 10.95 vs. 65.63 ± 12.60, p < 0.000), and had more comorbidities. After age-adjustment, the higher prevalence of comorbidities, like diabetes (age-adjusted odds ratio [OR] 2.48, 95% confidence intervals [CI] 1.45- 4.24), hypertension (OR 1.78, 95% CI 1.15-2.76) and history of congestive heart failure (OR 2.14, 95% CI 1.32-3.46) in women was preserved.Women were more frequently treated with diuretics (OR 2.68, 95% CI 1.69-4.25) and less frequently with statins (OR 0.61, 95% CI 0.39-0.96), after ageadjustment. Although thrombolytic therapy, coronary angiography and angioplasty were performed less frequently in women, these differences disappeared after age-adjustment. Female gender was not an independent predictor of 30-day mortality after AMI, crude OR was 1.39, 95% CI 0.80 to 2.41, adjustment for age and other covariates reduced OR to 0.98, 95% CI 0.44 to 2.20. Conclusions — Among AMI-patients, age but not gender is an important determinant of care and early mortality.

Cancer patient survival in Estonia 1995–2009: Time trends and data quality

BACKGROUND Survival from most cancers in Estonia has been consistently below European average. The objective of this study was to examine recent survival trends in Estonia and to quantify the effect on survival estimates of the temporary disruption of the Estonian Cancer Registry (ECR) practices in 2001-2007 when death certificates could not be used for case ascertainment. PATIENTS AND METHODS ECR data on all adult cases of 16 common cancers diagnosed in Estonia during 1995-2008 and followed up for vital status until 2009 were used to estimate relative survival ratios (RSR). We used cohort analysis for patients diagnosed in 1995-1999 and 2000-2004; and period hybrid approach to obtain the most recent estimates (2005-2009). We compared five-year RSRs calculated from data sets with and without death certificate initiated (DCI) cases. RESULTS A total of 64328 cancer cases were included in survival analysis. Compared with 1995-1999, five-year age-standardized RSR increased 20 percent units for prostate cancer, reaching 76% in 2005-2009. A rise of 10 percent units or more was also seen for non-Hodgkin lymphoma (five-year RSR 51% in 2005-2009), and cancers of rectum (49%), breast (73%) and ovary (37%). The effect of including/excluding DCI cases from survival analysis was small except for lung and pancreatic cancers. CONCLUSIONS Relative survival continued to increase in Estonia during the first decade of the 21st century, although for many cancers, a gap between Estonia and more affluent countries still exists. Cancer control efforts should aim at the reduction of risk factors amenable to primary prevention, but also at the improvement of early diagnosis and ensuring timely and optimal care to all cancer patients.

Time trends in population-based breast cancer survival in Estonia: analysis by age and stage.

Abstract Background. Survival from breast cancer (BC) in Estonia has been consistently among the lowest in Europe. The aim of this study was to examine most recent trends in BC survival in Estonia by age and stage. The trends in overall BC incidence and mortality are also shown in the paper. Material and methods. Estonian Cancer Registry data on all cases of BC, diagnosed in women in Estonia during 1995–2007 (n = 7424) and followed up for vital status through 2009, were used to estimate relative survival ratios (RSR). Period hybrid approach was used to obtain the most recent estimates (2005–2009). Stage was classified as localized, local/regional spread or distant. Results. BC incidence continued to rise throughout the study period, but mortality has been in steady decline since 2000. The distribution of patients shifted towards older age and earlier stage at diagnosis. Overall age-standardized five-year RSR increased from 63% in 1995–1999 to 74% in 2005–2009. Younger age groups experienced a more rapid improvement compared to women over 60. Significant survival increase was observed for both localized and locally/regionally spread BC with five-year RSRs reaching 96% and 70% in 2005–2009, respectively; the latest five-year RSR for distant BC was 11%. Survival for T4 tumors was poor and large age difference was seen for locally/regionally spread BC. Conclusions. Considerable improvement in BC survival was observed over the study period. Women under 60 benefited most from both earlier diagnosis and treatment advances of locally/regionally spread cancers. However, the survival gap with more developed countries persists. Further increase in survival, but also decline in BC mortality in Estonia could be achieved by facilitating early diagnosis in all age groups, but particularly among women over 60. Investigations should continue to clarify the underlying mechanisms of the stage-specific survival deficit in Estonia.

Sex-specific outcomes of diabetic patients with acute myocardial infarction who have undergone percutaneous coronary intervention: a register linkage study

BackgroundThe presence of diabetes mellitus poses a challenge in the treatment of patients with acute myocardial infarction (AMI). We aimed to evaluate the sex-specific outcomes of diabetic and non-diabetic patients with AMI who have undergone percutaneous coronary intervention (PCI).MethodsData of the Estonian Myocardial Infarction Registry for years 2006–2009 were linked with the Health Insurance Fund database and the Population Registry. Hazard ratios (HRs) with the 95% confidence intervals (CIs) for the primary composite outcome (non-fatal AMI, revascularization, or death whichever occurred first) and for the secondary outcome (all cause mortality) were calculated comparing diabetic with non-diabetic patients by sex.ResultsIn the final study population (n = 1652), 14.6% of the men and 24.0% of the women had diabetes. Overall, the diabetics had higher rates of cardiovascular risk factors, co-morbidities, and 3–4 vessel disease among both men and women (p < 0.01). Among women, the diabetic patients were younger, they presented later and less often with typical symptoms of chest pain than the non-diabetics (p < 0.01). Women with diabetes received aspirin and reperfusion for ST-segment elevation AMI less often than those without diabetes (p < 0.01). During a follow-up of over two years, in multivariate analysis, diabetes was associated with worse outcomes only in women: the adjusted HR for the primary outcome 1.44 (95% CI 1.05 − 1.96) and for the secondary outcome 1.83 (95% CI 1.17 − 2.89). These results were largely driven by a high (12.0%) mortality during hospitalization of diabetic women.ConclusionsDiabetic women with AMI who have undergone PCI are a high-risk group warranting special attention in treatment strategies, especially during hospitalization. There is a need to improve the expertise to detect AMI earlier, decrease disparities in management, and find targeted PCI strategies with adjunctive antithrombotic regimes in women with diabetes.

Use of mammography and Pap smear in Estonia, a country without organized cancer screening

SummaryObjectives:To analyze mammography and Pap smear status in Estonia where no organized population-based cancer screening is available.Methods:5000 individuals (aged 16–64) were randomly chosen from the national population register; among them, 1755 women filled out postal questionnaires.Results:50% of respondents aged 45–64 reported having taken a mammogram, 51% of women aged 25–64 had the Pap smear at least once in their lifetime. Corresponding figures for the past two years were 37% and 30%. Irrespective of age, women taking fewer tests over the past two years were rural workers, unemployed, and health behavior recommendations ignorers. In most cases, initiative for mammogram came from women, and from the physician in the case of Pap smear. Moderate increase in mammography use occurred after a project for early detection of breast cancer was launched.Conclusion:Women must continuously be informed that early detection of breast and cervical cancer is possible. Young women should be encouraged to ask for Pap testing. Knowledge of family physicians should be improved.

Estonian medical birth registry 1992–1994: Association of risk factors with perinatal mortality

OBJECTIVE To investigate the association of different maternal sociodemographic characteristics and infant sex with perinatal mortality among primiparas and multiparas. STUDY DESIGN Analysis of routine data from the Estonian Medical Birth Registry covering the whole of Estonia. A total of 47 358 infants (including stillborns) with a birth weight 1000 g or more from 1992 through 1994 were studied. Perinatal mortality rate, crude odds ratio (OR) and adjusted OR (calculated by a logistic regression model) were used to evaluate the association. OR values were adjusted for maternal age at delivery, maternal ethnicity, educational level, residence, marital status, smoking status, history of previous abortion and infant sex. RESULTS The perinatal mortality rate was 12.2 per 1000 total births among primiparous and 14.3 among multiparous women. The highest adjusted ORs of perinatal deaths were found in older (35 years and over) primiparas (1.78; 95% confidence interval (CI 0.88-3.57)) and multiparas (1.81; 95% CI 1.29-2.55), in unmarried (single) primiparas (1.59; 95% CI 1.14-2.20) and multiparas (1.98; 95% CI 1.29-3.05), in smoking primiparas (1.69; 95% CI 1.09-2.63) and multiparas (1.51; 95% CI 1.02-2.25), and in multiparas with unknown smoking status (1.98; 95% CI 1.18-3.33). CONCLUSION The study provides further evidence that perinatal mortality is positively associated with increased maternal age, unmarried (single) status and smoking.

Avoidable mortality in Estonia: Exploring the differences in life expectancy between Estonians and non-Estonians in 2005–2007

OBJECTIVES A considerable increase in social inequalities in mortality was observed in Eastern Europe during the post-communist transition. This study evaluated the contribution of avoidable causes of death to the difference in life expectancy between Estonians and non-Estonians in Estonia. STUDY DESIGN Descriptive study. METHODS Temporary life expectancy (TLE) was calculated for Estonian and non-Estonian men and women aged 0-74 years in 2005-2007. The ethnic TLE gap was decomposed by age and cause of death (classified as preventable or treatable). RESULTS The TLE of non-Estonian men was 3.53 years less than that of Estonian men, and the TLE of non-Estonian women was 1.36 years less than that of Estonian women. Preventable causes of death contributed 2.19 years to the gap for men and 0.78 years to the gap for women, while treatable causes contributed 0.67 and 0.33 years, respectively. Cardiorespiratory conditions were the major treatable causes of death, with ischaemic heart disease alone contributing 0.29 and 0.08 years to the gap for men and women, respectively. Conditions related to alcohol and substance use represented the largest proportion of preventable causes of death. CONCLUSIONS Inequalities in health behaviours underlie the ethnic TLE gap in Estonia, rather than inequalities in access to health care or the quality of health care. Public health interventions should prioritize primary prevention aimed at alcohol and substance use, and should be implemented in conjunction with wider social policy measures.

Use of evidence-based pharmacotherapy after myocardial infarction in Estonia

BackgroundMortality from cardiovascular disease in Estonia is among the highest in Europe. The reasons for this have not been clearly explained. Also, there are no studies available examining outpatient drug utilization patterns in patients who suffered from acute myocardial infarction (AMI) in Estonia. The objective of the present study was to examine drug utilization in different age and gender groups following AMI in Estonia.MethodsPatients admitted to hospital with AMI (ICD code I21-I22) during the period of 01.01.2004-31.12.2005 and who survived more than 30 days were followed 365 days from the index episode. Data about reimbursed prescriptions of beta-blockers (BBs), angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs) and statins for these patients was obtained from the database of the Estonian Health Insurance Fund. Data were mainly analysed using frequency tables and, where appropriate, the Pearsons χ2 test, the Mann-Whitney U-test and the t-test were used. A logistic regression method was used to investigate the relationship between drug allocation and age and gender. We presented drug utilization data as defined daily dosages (DDD) per life day in four age groups and described proportions of different combinations used in men and women.ResultsFour thousand nine hundred patients were hospitalized due to AMI and 3854 of them (78.7%) were treated by BBs, ACE/ARBs and/or statins. Of the 4025 inpatients who survived more than 30 days, 3799 (94.4%) were treated at least by the one of drug groups studied. Median daily dosages differed significantly between men and women in the age group 60-79 years for BBs and ACE/ARBs, respectively. Various combinations of the drugs studied were not allocated in equal proportions for men and women, although the same combinations were the most frequently used for both genders. The logistic regression analysis adjusted to gender and age revealed that some combinations of drugs were not allocated similarly in different age and gender groups.ConclusionsMost of the patients were prescribed at least one of commonly recommended drugs. Only 40% of them were treated by combinations of beta-blockers, ACE inhibitors/angiotensin II receptor blockers and statins, which is inconsistent with guideline recommendations in Estonia. Standards of training and quality programs in Estonia should be reviewed and updated aiming to improve an adherence to guidelines of management of acute myocardial infarction in all age and gender groups.