Harper Gilmour

Gender and survival: A population-based study of 201,114 men and women following a first acute myocardial infarction

OBJECTIVES We tested the hypotheses that the effect of gender on short-term case fatality following a first admission for acute myocardial infarction (AMI) varies with age, and that this effect is offset by differences in the proportion of men and women who survive to reach hospital. BACKGROUND Evidence is conflicting regarding the effect of gender on prognosis after AMI. METHODS All 201,114 first AMIs between 1986 and 1995 were studied. Both 30-day and 1-year case fatality were analyzed for the 117,749 patients hospitalized and for all first AMIs, including deaths before hospitalization. The effect of gender and its interaction with age on survival was examined using multivariate modeling. RESULTS Gender-based differences in survival varied according to age in hospitalized patients, with younger women having higher 30-day case fatality than men (e.g., <55 years, women 6.5% vs. 4.8% men, p < 0.0001). When deaths from first AMI before hospitalization were included in 30-day case fatality, women were less likely to die (adjusted odds ratio 0.9, confidence interval 0.89 to 0.93). Gender was not an independent predictor of one-year survival (p = 0.16). CONCLUSIONS Female gender increases the probability of surviving to reach hospital, and this outweighs the excess risk of death occurring in younger women following hospitalization. Overall, men have a higher 30-day case fatality than women. Women do not fare worse than men after AMI when age and other factors are taken into account. However, men are more likely to die before hospitalization.

Employment status and health: understanding the health of the economically inactive population in Scotland

BackgroundAlthough the association between health and unemployment has been well examined, less attention has been paid to the health of the economically inactive (EI) population. Scotland has one of the worst health records compared to any Western European country and the EI population account for 23% of the working age population. The aim of this study is to investigate and compare the health outcomes and behaviours of the employed, unemployed and the EI populations (further subdivided into the permanently sick, looking after home and family [LAHF] and others) in Scotland.MethodsUsing data from the 2003 Scottish Health Survey, the differences in health and health behaviours among the employed, unemployed and the subgroups of the EI population were examined.ResultsBoth low educational attainment and residence in a deprived community were more likely in the permanently sick group. The LAHF and the unemployed showed worse self-reported health and limiting longstanding illness compared to the employed but no significant differences were observed between these groups. The permanently sick group had significantly poorer health outcomes than all the other economic groups. Similar to the unemployed and LAHF they are more likely to smoke than the employed but less likely (along with LAHF and ‘others’) to exhibit heavy alcohol consumption. Interestingly, the LAHF showed better mental health than the rest of the EI group, but a similar mental health status to the unemployed. On the physical health element of lung function, the LAHF were no worse than the employed.ConclusionWhile on-going health promotion and vocational rehabilitation efforts need to be directed towards all, our data suggests that the EI group is at higher risk and policies and strategies directed at this group may need particular attention.

Dental practitioners and ill health retirement: causes, outcomes and re-employment

Aim The aim of this project was, by means of a questionnaire to ill health retirees, to determine the factors which have contributed to the premature retirement of general dental practitioners (GDPs) due to ill health.Methods A questionnaire was designed to determine the effects of illness and ill health retirement (IHR) on the lives of those dentists who were affected. This was distributed to 207 dentists who were known to have retired because of ill health but were not suffering from serious, debilitating or life-threatening illnesses.Results A total of 189 questionnaires were returned. The mean age at retirement of respondents was 51.5 years, with a range of 31 to 62 years. Of the respondents, 90% selected general dental practitioner as their last job title. The most common cause of IHR was musculoskeletal disorders (55%), followed by mental and behavioural disorders (28%). A majority of respondents (90%) considered that their ill health was work related. Sixty-three percent of respondents stated that they were able to keep working until their retirement, 34% of respondents stated that they would have liked to have been offered part-time work as an alternative to full retirement, and 27% of dentists reported to have found re-employment since their retirement. In univariate analyses, re-employment of dentists after IHR was significantly associated with age, having dependants, cause of IHR, health having improved and wanting to work again. Multiple logistic regression analyses showed that a combination of age, having dependents and cause of IHR was predictive of re-employment status (p = 0.024).Conclusion This study used a database of dentists who were ill health retired and who were not suffering from life threatening illnesses The results confirmed that the majority were able to work up to their retirement and a similar number would have liked to continue working, particularly if part-time work had been possible. It seems likely that many of the ill health retirees could have been retained in the dental workforce with better support or opportunities for more flexible working.

Impact of anti-tumour necrosis factor therapy on the weight of patients with rheumatoid arthritis

The role of tumour necrosis factor α (TNFα) in cachexia is established.1 More recent studies have found that adipocytes of obese animals and humans express higher levels of TNF than controls2 3; in this phenotype higher concentrations of TNFα are thought to limit further fat accumulation.4 5 We observed weight gain was becoming an increasing problem in some of our patients with rheumatoid arthritis (RA) given anti-TNF therapy. Several patients had raised this concern at review appointments and one even elected to discontinue anti-TNF treatment owing to weight gain. The authors therefore undertook a longitudinal retrospective review of …

Diamorphine for pain relief in labour : a randomised controlled trial comparing intramuscular injection and patient-controlled analgesia

Objectives  To compare the efficacy of diamorphine administered by a patient‐controlled pump (patient‐controlled analgesia) with intramuscular administration for pain relief in labour.

Retrospective evaluation of extended leave of absence in Scotland 1988-94

Abstract Extended leave of absence (ELOA) is defined as leave of absence over 6 months and could be unlimited in Scotland until 1996. Patients have previously been detained under s.18 of the Mental Health (Scotland) Act 1984. A retrospective evaluation of use of ELOA was carried out using data held by the Mental Welfare Commission for Scotland. Records were used to describe reasons for using ELOA, support and service use. Over the period 1988–94 there were 534 people who had at least one episode of ELOA over 6 months and, of these, 250 had at least one episode of ELOA over 12 months. A diagnosis of schizophrenia occurs in 73% of patients. Lack of insight and threat of stopping medication are the most common reasons for using ELOA. Although threat to others is recorded more often than threat to self, self-neglect is recorded more often than either. The outcome of ELOA by year results in 30% of patients being discharged and 23% recalled to hospital. Of the total, 75% receive good support from at least one r...

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

PURPOSE This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting. METHODS This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed. RESULTS Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86). CONCLUSIONS This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores.

Developing and Validating a Predictive Model for Stroke Progression

Background: Progression is believed to be a common and important complication in acute stroke, and has been associated with increased mortality and morbidity. Reliable identification of predictors of early neurological deterioration could potentially benefit routine clinical care. The aim of this study was to identify predictors of early stroke progression using two independent patient cohorts. Methods: Two patient cohorts were used for this study – the first cohort formed the training data set, which included consecutive patients admitted to an urban teaching hospital between 2000 and 2002, and the second cohort formed the test data set, which included patients admitted to the same hospital between 2003 and 2004. A standard definition of stroke progression was used. The first cohort (n = 863) was used to develop the model. Variables that were statistically significant (p < 0.1) on univariate analysis were included in the multivariate model. Logistic regression was the technique employed using backward stepwise regression to drop the least significant variables (p > 0.1) in turn. The second cohort (n = 216) was used to test the performance of the model. The performance of the predictive model was assessed in terms of both calibration and discrimination. Multiple imputation methods were used for dealing with the missing values. Results: Variables shown to be significant predictors of stroke progression were conscious level, history of coronary heart disease, presence of hyperosmolarity, CT lesion, living alone on admission, Oxfordshire Community Stroke Project classification, presence of pyrexia and smoking status. The model appears to have reasonable discriminative properties [the median receiver-operating characteristic curve value was 0.72 (range 0.72–0.73)] and to fit well with the observed data, which is indicated by the high goodness-of-fit p value [the median p value from the Hosmer-Lemeshow test was 0.90 (range 0.50–0.92)]. Conclusion: The predictive model developed in this study contains variables that can be easily collected in practice therefore increasing its usability in clinical practice. Using this analysis approach, the discrimination and calibration of the predictive model appear sufficiently high to provide accurate predictions. This study also offers some discussion around the validation of predictive models for wider use in clinical practice.

Who Wants Fitness Checks?: Some Preliminary Findings

This paper reports data from a survey of a random sample of the British general public in one large city, drawn from the electoral roll. Subjects were invited to have a fitness check and to participate in an exercise programme. Age, gender and employment status were found to be related to willingness to volunteer for a fitness check and motivation to participate in an exercise programme. The implications of this for population based approaches to positive health behaviour are discussed.