David J Godden

Long term outcomes in men screened for abdominal aortic aneurysm: prospective cohort study

Objective To determine whether there is a relation between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm. Design Prospective cohort study. Setting Highland and Western Isles (a large, sparsely populated area of Scotland). Participants 8146 men aged 65-74. Main outcome measures Morbidity and mortality in relation to presence of abdominal aortic aneurysm and three categories of aortic diameter (≤24 mm, 25-29 mm, and ≥30 mm). Results When screened, 414 men (5.1%) had an aneurysm (diameter ≥30 mm), 669 (8.2%) an aortic diameter of 25-29 mm, and 7063 (86.7%) an aortic diameter of ≤24 mm. The cohort was followed up for a median of 7.4 (interquartile range 6.9-8.2) years. Mortality was significantly associated with aortic diameter: 512 (7.2%) men in the ≤24 mm group died compared with 69 (10.3%) in the 25-29 mm group and 73 (17.6%) in the ≥30 mm group. The mortality risk in men with an aneurysm or with an aorta measuring 25-29 mm was significantly higher than in men with an aorta of ≤24 mm. The increased mortality risk in the 25-29 mm group was reduced when taking confounders such as smoking and known heart disease into account. After adjustment, compared with men with an aortic diameter of ≤24 mm, the risk of hospital admission for cardiovascular disease and chronic obstructive pulmonary disease was significantly higher in men with aneurysm and those with aortas measuring 25-29 mm. Men with an aneurysm also had an increased risk of hospital admission for cerebrovascular disease, atherosclerosis, peripheral arterial disease, and respiratory disease. In men with aortas measuring 25-29 mm, the risk of hospital admission with abdominal aortic aneurysm was significantly higher than in men with an aorta of ≤24 mm (adjusted hazard ratio 6.7, 99% confidence interval 3.4 to 13.2) and this increased risk became apparent two years after screening. Conclusions Men with abdominal aortic aneurysm and those with aortic diameters measuring 25-29 mm have an increased risk of mortality and subsequent hospital admissions compared with men with an aorta diameter of ≤24 mm. Consideration should be given to control of risk factors and to rescreening men with aortas measuring 25-29 mm at index scanning.

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial

Objective To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women. Design Cluster randomised controlled trial with prospective mixed method embedded case studies to evaluate implementation processes. Setting Primary care in Scotland. Participants Pregnant women, breastfeeding mothers, and babies registered with 14 of 66 eligible clusters of general practices (localities) in Scotland that routinely collect breastfeeding outcome data. Intervention Localities set up new breastfeeding groups to provide population coverage; control localities did not change group activity. Main outcome measures Primary outcome: any breast feeding at 6-8 weeks from routinely collected data for two pre-trial years and two trial years. Secondary outcomes: any breast feeding at birth, 5-7 days, and 8-9 months; maternal satisfaction. Results Between 1 February 2005 and 31 January 2007, 9747 birth records existed for intervention localities and 9111 for control localities. The number of breastfeeding groups increased from 10 to 27 in intervention localities, where 1310 women attended, and remained at 10 groups in control localities. No significant differences in breastfeeding outcomes were found. Any breast feeding at 6-8 weeks declined from 27% to 26% in intervention localities and increased from 29% to 30% in control localities (P=0.08, adjusted for pre-trial rate). Any breast feeding at 6-8 weeks increased from 38% to 39% in localities not participating in the trial. Women who attended breastfeeding groups were older (P<0.001) than women initiating breast feeding who did not attend and had higher income (P=0.02) than women in the control localities who attended postnatal groups. The locality cost was £13 400 (€14 410;

Psychological impact of foot-and-mouth disease on farmers

20 144) a year. Conclusion A policy for providing breastfeeding groups in relatively deprived areas of Scotland did not improve breastfeeding rates at 6-8 weeks. The costs of running groups would be similar to the costs of visiting women at home. Trial registration Current Controlled Trials ISRCTN44857041.

Adoption of telemedicine in Scottish remote and rural general practices: a qualitative study.

The outbreak of foot-and-mouth disease in the United Kingdom during 2001 had devastating consequences on rural communities. The farming community was already under major stress from factors such as BSE and low incomes. This study aimed to investigate the psychological impact of the outbreak on farmers by comparing a badly affected area (Cumbria) with an unaffected area (Scottish Highlands), using the General Health Questionnaire. A second aim was to examine sources of psychological support that farmers had sought; and what other supports should be available. Farmers were contacted via a postal survey; the response rate was 29%. Cumbrian farmers obtained significantly higher scores than their Highland counterparts, although high levels of psychological morbidity were obtained in both samples. Farmers were more likely to turn to their own communities, and to veterinary surgeons, for support. Few would welcome more support from health or social work authorities, many preferring to use anonymous supports such as the internet or self help booklets. However in view of the low response rate, caution must be exercised in interpreting these results.

Annual review of patients with sleep apnea/hypopnea syndrome--a pragmatic randomised trial of nurse home visit versus consultant clinic review.

We conducted a qualitative interview study to explore the factors that have facilitated and prevented the adoption of telemedicine in general practice in remote and rural Scotland. Face-to-face interviews were carried out with general practitioners (GPs) and practice nurses in 26 of Scotlands most remote practices and five of the seven most rural health boards. The interview study found that GPs were more positive about the use of computers and telemedicine than nurses. Although electronic access to simple data, such as laboratory results, had become widely accepted, most respondents had very little experience of more sophisticated telemedicine applications, such as videoconferencing. There was widespread scepticism about the potential usefulness of clinical applications of telemedicine, although it was perceived to have potential benefit in facilitating access to educational resources. A number of barriers to the adoption of telemedicine were reported, including concerns that videoconferencing could diminish the quality of communication in educational and clinical settings, and that telemedicine would not fit easily with the organizational routines of the practices. Policy-makers should prioritize strategies to develop educational programmes, as these are more likely to succeed than clinical initiatives. It may then follow that clinicians will see opportunities for use in their clinical work.

Urban versus rural populations' views of health care in Scotland.

BACKGROUND This pragmatic randomised, controlled trial investigated annual review of patients with sleep apnea/hypopnea syndrome (SAHS). Clinical outcomes and costs were compared for consultant clinic review versus specialist nurse home visit. METHOD One hundred and seventy-four patients were randomised to annual review by consultant clinic appointment or by specialist nurse home visit. SAHS symptoms, Epworth score, hospital anxiety and depression scale (HADS), Short Form-36 (SF-36) and hours of use of constant positive airway pressure (CPAP) were measured before and 3 months after review. The costs and patient preference for review were determined. RESULTS After review, both groups significantly increased CPAP use (mean (SD) increase: nurse, 0.66 (1.71) h; consultant, 0.45 (1.69) h) and reduced symptom scores (nurse, -2 (7); consultant, -3 (9)), compared to baseline. There were no differences between groups in these improvements, or in HADS or SF-36 scores. Average duration of a nurse home visit, excluding travel time, was 26 (6) min. Total NHS cost per visit was 52.26 UK pounds (49.85) (

Group pulmonary rehabilitation delivered to the home via the internet: feasibility and patient perception

83.62 (79.76)), of which 6.57 UK pounds (1.43) (

Screening for abdominal aortic aneurysm in a geographically isolated area.

10.51 (2.29)) reflected time spent with the patient and the remainder was travel cost. Average duration of consultant review was 10 (6) min, total NHS cost 6.21 UK pounds (3.99) (

Rational development of telehealth to support primary care respiratory medicine: patient distribution and organisational factors

9.94 (6.38)). However, the cost to the patient of attending the clinic was 23.63 UK pounds (23.21) (

Geography, private costs and uptake of screening for abdominal aortic aneurysm in a remote rural area

37.81 (37.13)). Patient preference for review was nurse 16%, consultant 19%, and no preference 65%. CONCLUSION Following annual review, use of CPAP increased and symptoms improved. Outcomes were similar for consultant and nurse led review. Home visits were expensive for the healthcare provider, whereas clinic attendance incurred substantial costs to the patient. The majority of patients would accept nurse review for their sleep apnea management.