Edwin Amalraj Raja

Maternal obesity during pregnancy and premature mortality from cardiovascular event in adult offspring: follow-up of 1 323 275 person years

Objectives To determine whether maternal obesity during pregnancy is associated with increased mortality from cardiovascular events in adult offspring. Design Record linkage cohort analysis. Setting Birth records from the Aberdeen Maternity and Neonatal databank linked to the General Register of Deaths, Scotland, and the Scottish Morbidity Record systems. Population 37 709 people with birth records from 1950 to present day. Main outcome measures Death and hospital admissions for cardiovascular events up to 1 January 2012 in offspring aged 34-61. Maternal body mass index (BMI) was calculated from height and weight measured at the first antenatal visit. The effect of maternal obesity on outcomes in offspring was tested with time to event analysis with Cox proportional hazard regression to compare outcomes in offspring of mothers in underweight, overweight, or obese categories of BMI compared with offspring of women with normal BMI. Results All cause mortality was increased in offspring of obese mothers (BMI >30) compared with mothers with normal BMI after adjustment for maternal age at delivery, socioeconomic status, sex of offspring, current age, birth weight, gestation at delivery, and gestation at measurement of BMI (hazard ratio 1.35, 95% confidence interval 1.17 to 1.55). In adjusted models, offspring of obese mothers also had an increased risk of hospital admission for a cardiovascular event (1.29, 1.06 to 1.57) compared with offspring of mothers with normal BMI. The offspring of overweight mothers also had a higher risk of adverse outcomes. Conclusions Maternal obesity is associated with an increased risk of premature death in adult offspring. As one in five women in the United Kingdom is obese at antenatal booking, strategies to optimise weight before pregnancy are urgently required.

Association between maternal body mass index during pregnancy, short-term morbidity, and increased health service costs: a population-based study.

To investigate the impact of maternal body mass index (BMI, kg/m2) on clinical complications, inpatient admissions, and additional short‐term costs to the National Health Service (NHS) in Scotland.

Outcomes following hysterectomy or endometrial ablation for heavy menstrual bleeding: retrospective analysis of hospital episode statistics in Scotland

Please cite this paper as: Cooper K, Lee A, Chien P, Raja E, Timmaraju V, Bhattacharya S. Outcomes following hysterectomy or endometrial ablation for heavy menstrual bleeding: retrospective analysis of hospital episode statistics in Scotland. BJOG 2011; DOI: 10.1111/j.1471‐0528.2011.03011.x

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

Background:There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.Methods:A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.Results:There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P⩽0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.Conclusions:GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.

Reproductive outcomes following induced abortion: a national register- based cohort study in Scotland

Objective To investigate reproductive outcomes in women following induced abortion (IA). Design Retrospective cohort study. Setting Hospital admissions between 1981 and 2007 in Scotland. Participants Data were extracted on all women who had an IA, a miscarriage or a live birth from the Scottish Morbidity Records. A total of 120 033, 457 477 and 47 355 women with a documented second pregnancy following an IA, live birth and miscarriage, respectively, were identified. Outcomes Obstetric and perinatal outcomes, especially preterm delivery in a second ongoing pregnancy following an IA, were compared with those in primigravidae, as well as those who had a miscarriage or live birth in their first pregnancy. Outcomes after surgical and medical termination as well as after one or more consecutive IAs were compared. Results IA in a first pregnancy increased the risk of spontaneous preterm birth compared with that in primigravidae (adjusted RR (adj. RR) 1.37, 95% CI 1.32 to 1.42) or women with an initial live birth (adj. RR 1.66, 95% CI 1.58 to 1.74) but not in comparison with women with a previous miscarriage (adj. RR 0.85, 95% CI 0.79 to 0.91). Surgical abortion increased the risk of spontaneous preterm birth compared with medical abortion (adj. RR 1.25, 95% CI 1.07 to 1.45). The adjusted RRs (95% CI) for spontaneous preterm delivery following two, three and four consecutive IAs were 0.94 (0.81 to 1.10), 1.06 (0.76 to 1.47) and 0.92 (0.53 to 1.61), respectively. Conclusions The risk of preterm birth after IA is lower than that after miscarriage but higher than that in a first pregnancy or after a previous live birth. This risk is not increased further in women who undergo two or more consecutive IAs. Surgical abortion appears to be associated with an increased risk of spontaneous preterm birth in comparison with medical termination of pregnancy. Medical termination was not associated with an increased risk of preterm delivery compared to primigravidae.

Obstetric and perinatal outcomes after either fresh or thawed frozen embryo transfer: an analysis of 112,432 singleton pregnancies recorded in the Human Fertilisation and Embryology Authority anonymized dataset

OBJECTIVE To explore obstetric and perinatal outcomes in singleton pregnancies occurring as a result of fresh and thawed frozen embryo transfer using anonymized Human Fertilisation and Embryology Authority data. DESIGN Retrospective cohort study. SETTING Not applicable. PATIENT(S) Singleton births after IVF/intracytoplasmic sperm injection cycles in the United Kingdom (1991-2011). INTERVENTION(S) A total of 112,432 cycles (95,911 fresh and 16,521 frozen) were analyzed using multivariate logistic regression to explore associations between type of embryo transferred (frozen vs. fresh) and obstetric and perinatal outcomes. Relative risks (RRs) and their 99.5% confidence intervals (CIs) were calculated using Stata 14 MP, adjusting for potential confounders. MAIN OUTCOME MEASURE(S) Birth weight. RESULT(S) The adjusted RR (99.5% CI) of low birth weight [0.73 (0.66-0.80)] and very low birth weight [0.78 (0.63-0.96)] were all lower after frozen embryo transfer; however, RR of having a high birth weight baby was higher [1.64 (1.53-1.76)]. There was no difference in RR of preterm birth [0.96 (0.88-1.03)], very preterm birth [0.86 (0.70-1.05)], and congenital anomalies [0.86 (0.73-1.01)]. CONCLUSION(S) The findings of low birth and very low birth weight after thawed frozen embryo transfer are consistent with the literature and provide reassurance regarding the outcome of pregnancies after frozen embryo transfers. However, they highlight the possibility of high birth weight in these babies. Because these results are based on observational data, further evidence from randomized, controlled trials is needed before elective cryopreservation of all embryos is practiced in preference to the current practice of transfer of fresh embryos.

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival

Background:British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.Methods:Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.Results:On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.Conclusions:Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service’s primary emphasis should be on quality and outcomes rather than on time to treatment.

Maternal Obesity During Pregnancy Associates With Premature Mortality and Major Cardiovascular Events in Later Life

One in 5 pregnant women is obese but the impact on later health is unknown. We aimed to determine whether maternal obesity during pregnancy associates with increased premature mortality and later life major cardiovascular events. Maternity records of women who gave birth to their first child between 1950 and 1976 (n=18 873) from the Aberdeen Maternity and Neonatal databank were linked to the National Register of Deaths, Scotland and Scottish Morbidity Record. The effect of maternal obesity at first antenatal visit on death and hospital admissions for cardiovascular events was tested using time-to-event analysis with Cox proportional hazard regression to compare outcomes of mothers in underweight, overweight, or obese body mass index (BMI) categories compared with normal BMI. Median follow-up was at 73 years. All-cause mortality was increased in women who were obese during pregnancy (BMI>30 kg/m2) versus normal BMI after adjustment for socioeconomic status, smoking, gestation at BMI measurement, preeclampsia, and low birth weight (hazard ratio, 1.35; 95% confidence interval, 1.02–1.77). In adjusted models, overweight and obese mothers had increased risk of hospital admission for a cardiovascular event (1.16; 1.06–1.27 and 1.26; 1.01–1.57) compared with normal BMI mothers. Adjustment for parity largely unchanged the hazard ratios (mortality: 1.43, 1.09–1.88; cardiovascular events overweight: 1.17, 1.07–1.29; and obese: 1.30, 1.04–1.62). In conclusion, maternal obesity is associated with increased risk of premature death and cardiovascular disease. Pregnancy and early postpartum could represent an opportunity for interventions to identify obesity and reduce its adverse consequences.

Maternal and perinatal consequences of antepartum haemorrhage of unknown origin

To explore the risk of adverse maternal and perinatal outcomes in women with antepartum bleeding of unknown origin (ABUO).

Prevalence and year-on-year trends in childhood thinness in a whole population study

Background The burden of childhood thinness in the UK is poorly understood. The aim of this study was to describe the prevalence and year-on-year trends of childhood thinness in a population born between 1970 and 2006 in North East Scotland. Methods Measurements were routinely collected by school nurses as part of school medical entry. Trends in International Obesity Task Force thinness grades 1, that is, body mass index (BMI) corresponding to adult BMI <18.5 kg/m2 but ≥17 kg/m2 or grade ≥2, that is, corresponding to adult BMI <17 kg/m2 were analysed over time by sex and socioeconomic deprivation quintile. Results Data were obtained for 194 391 children, 52% boys, mean age 5.6 years (SD 0.8). The prevalence of thinness grade 1 was 6.5% (95% CI 5.9% to 7.2%) and 4.8% (4.2% to 5.5%) for those born in 1970 and 2006, respectively, but between these years was variable with the fluctuations being greater for boys than girls. The prevalence of thinness grade ≥2 fell for those born between 1974 and 1985 from 6.1% (5.5% to 6.8%) to 1.3%, (1.0% to 1.6%) and remained relatively stable thereafter in boys and girls. Thinness grade ≥2 was initially less prevalent in more affluent communities, but for those born in 1990 and afterwards, prevalence was equal across deprivation quintiles. In contrast, there was no interaction between deprivation quintile and year of birth for thinness grade 1. Conclusions Thinness has become less common in this population. While thinness was initially more prevalent among deprived communities, this association is no longer apparent.