Leicester Gill

Depression and anxiety in people with inflammatory bowel disease.

STUDY OBJECTIVE To determine whether depression or anxiety co-occurs with ulcerative colitis (UC) or Crohns disease (CD) more often than expected by chance, and, if so, whether the mental disorders generally precede or follow the inflammatory bowel diseases (IBD). DESIGN Nested case-control studies using a database of linked hospital record abstracts. SETTING Southern England. MAIN RESULTS Both depression and anxiety preceded UC significantly more often than would be predicted from the control populations experience. The associations were strongest when the mental conditions were diagnosed shortly before UC, although the association between depression and UC was also significant when depression preceded UC by five or more years. Neither depression nor anxiety occurred before CD more often than expected by chance. However, depression and anxiety were significantly more common after CD; the associations were strongest in the year after the initial record of CD. UC was followed by anxiety, but not by depression, more often than expected by chance and, again, the association was strongest within one year of diagnosis with UC. CONCLUSIONS The concentration of risk of depression or anxiety one year or less before diagnosis with UC suggests that the two psychiatric disorders might be a consequence of early symptoms of the as yet undiagnosed gastrointestinal condition. The data are also, however, compatible with the hypothesis that the psychiatric disorders could be aetiological factors in some patients with UC. Most of the excess anxiety or depression diagnosed subsequent to diagnosis of IBD occurs during the year after IBD is diagnosed and the probable explanation is that the mental disorders are sequelae of IBD.

Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality.

OBJECTIVES--To report the incidence of elective total hip replacement and postoperative mortality, emergency readmission rates, and the demographic factors associated with these rates in a large defined population. DESIGN--Analysis of linked, routine abstracts of hospital inpatient records and death certificates. SETTING--10 hospitals in six districts in Oxford Regional Health Authority covered by the Oxford record linkage study. SUBJECTS--Records for 11,607 total hip replacements performed electively in 1976-85. MAIN OUTCOME MEASURES--Incidence of operation, postoperative mortality, relative mortality ratios, and incidence of emergency readmission. RESULTS--NHS operation rates increased over time from 43 to 58 operations/100,000 population. Variation in operation rates between districts reduced over time. Operation rates were on average 25% higher in women than men. There were 93 deaths (11/1000 operations) within 90 days of the operation and 208 emergency readmissions (28/1000 operations) within 28 days of discharge. Postoperative mortality and emergency readmission rates increased with age. No significant trend with time was found. Mortality in the 90 days after the operation was 2.5-fold higher (1.9 to 3.0) than in the rest of the first postoperative year. This represented an estimated excess of 6.5 (4.2 to 8.8) early postoperative deaths/1000 operations. Most deaths were ascribed to cardiovascular events. Thromboembolic disease was the commonest reason for emergency readmission. CONCLUSIONS--The pronounced increase in operations in districts with initially low rates suggests a trend towards greater equity in the local provision of NHS hip arthroplasty. The early postoperative clusters of deaths attributed to cardiovascular disease and of readmissions for thromboembolic disease suggest that there is scope for investigating ways of reducing the incidence of major adverse postoperative events.

Computerised linking of medical records: methodological guidelines.

OBJECTIVES--To report on the development of computer assisted methods for linking medical records and record abstracts. DESIGN--The methods include file blocking, to put records in an order which makes searching efficient; matching, which is the process of comparing records to determine whether they do or do not relate to the same person; linkage, which is the process of assembling correctly matched records into a time sequenced composite record for the individual; and validation checks and corrections, in which any inconsistencies between different records for the same person are identified and corrected. SETTING--The dataset comprising the Oxford record linkage study which includes hospital inpatient records and vital records. RESULTS AND CONCLUSIONS--Probability matching, using an array of identifiers, achieves much higher levels of correct matching than is generally achievable by exact character by character comparisons. The increasing use of information technology to store data about health and health care means that there is increasing scope to link records for research and for patient care. Sophisticated methods to achieve this on a large scale are now available.

Olive oil, diet and colorectal cancer: an ecological study and a hypothesis

STUDY OBJECTIVES Colorectal cancer (CRC) is a common cancer in many western countries and is probably caused in part by dietary factors. Southern European countries have lower incidence rates of CRC than many other western countries. It was postulated that, because olive oil is thought to influence bile salt secretion patterns in rats, it may influence the occurrence of CRC. The purpose of this study was to compare national levels of dietary factors, with particular reference to olive oil, with national differences in CRC incidence. DESIGN Ecological study using existing international databases. Incidence rates for CRC, food supply data, and olive oil consumption data were extracted from published sources, combined, and analysed to calculate the correlations between CRC and 10 dietary factors. Associations were then explored using stepwise multiple regression. SETTING 28 countries from four continents. MAIN RESULTS 76% of the intercountry variation in CRC incidence rates was explained by three significant dietary factors—meat, fish and olive oil—in combination. Meat and fish were positively associated, and olive oil was negatively associated, with CRC incidence. CONCLUSION Olive oil may have a protective effect on the development of CRC. The proposed hypothesis is that olive oil may influence secondary bile acid patterns in the colon that, in turn, might influence polyamine metabolism in colonic enterocytes in ways that reduce progression from normal mucosa to adenoma and carcinoma.

Incidence of disease after vasectomy: a record linkage retrospective cohort study.

OBJECTIVE--To determine whether vasectomy is associated with an increased risk of several diseases, and in particular testicular cancer, after operation. DESIGN--Retrospective cohort study using linked medical record abstracts. SETTING--Six health districts in Oxford region. SUBJECTS--13,246 men aged 25-49 years who had undergone vasectomy between 1970 and 1986, and 22,196 comparison subjects who had been admitted during the same period for one of three specified elective operations, appendicitis, or injuries. MAIN OUTCOME MEASURES--Hospital admission and death after vasectomy or comparison event. RESULTS--The mean durations of follow up were 6.6 years for men with a vasectomy and 7.5 years for men with a comparison condition. The relative risk of cancer of the testis in the vasectomy cohort (4 cases) compared with that in the other cohorts (17 cases) was 0.46 (95% confidence interval 0.1 to 1.4), that of cancer of the prostate (1 v 5 cases) 0.44 (0.1 to 4.0), and that of myocardial infarction (97 v 226 cases) 1.00 (0.8 to 1.3). There was no evidence of an increase associated with vasectomy in the incidence of a range of other diseases. CONCLUSIONS--Vasectomy was not associated with an increased risk of testicular cancer or the other diseases studied. With respect to prostatic cancer, while we found no cause for concern, longer periods of observation on large numbers of men are required.

Effect of spectacles on changes of spherical hypermetropia in infants who did, and did not, have strabismus

AIM To explore why emmetropisation fails in children who have strabismus. METHODS 289 hypermetropic infants were randomly allocated spectacles and followed. Changes in spherical hypermetropia were compared in those who had strabismus and those who did not. The effect of wearing glasses on these changes was assessed using t tests and regression analysis. RESULTS Mean spherical hypermetropia decreased in both eyes of “normal” children (p<0.001). The consistent wearing of glasses impeded this process in both eyes (p<0.007). In the children with strabismus, there were no significant changes in either eye, irrespective of treatment (p>0.05). CONCLUSIONS In contrast with normal infants, neither eye of those who had strabismus emmetropised, irrespective of whether the incoming vision was clear or blurred. It is suggested that these eyes did not “recognise” the signal of blurred vision, and that they remained long sighted because they were destined to squint. Hence, the children did not squint because they were long sighted, and glasses did not prevent them squinting.

Emmetropisation in normal and strabismic children and the associated changes of anisometropia.

The purpose of this study was to measure whether emmetropisation failed in children who had strabismus irrespective of their refraction in infancy, and to record simultaneous changes in anisometropia. We also report how often hypermetropia increased before these children presented with esotropia. A total of 2920 infants had a cycloplegic retinoscopy at age 5-7 months and again at 42 months or when defective vision was identified. Changes of refraction in 210 children with strabismus are compared with the remaining 2710 who did not. When the spherical equivalent of the fixing eyes was > +2.75 D in infancy, hypermetropia decreased less in both eyes of those who had microtropia (p <. 001) and heterotropia (p <. 001) than in normal children. When it was < +2.75 D, the spherical and/or cylindrical refraction more often remained outside the ‘normal’ range in both eyes of those who had microtropia and heterotropia (p <. 05). Emmetropisation was deficient in both eyes of at least 80% of these strabismic children irrespective of their refraction in infancy. Furthermore, in the strabismic children, the mean change of refraction was less (p <. 05) in their fellow eyes than in their fixing eyes, the difference between the two eyes being on average three times greater than that in those who had normal vision. Thus, anisometropia increased in 53% of those who had strabismus but remained within normal limits (< ca. 0.75 D spherical equivalent) in 94 % of those who did not.‘Abormal’ anisometropia in infancy did not, per se, permanently affect vision because 72% of all those who had it did not have strabismus. Finally, the spherical hypermetropia of fixing eyes increased in only 35% of the children with esotropia – similar to the incidence in those who had a microtropia (p =. 36). This does not obviously support the concept that increasing hypermetropia causes accommodation to increase before convergence.

Trends and social patterning of birthweight in Sheffield, 1985–94

AIM To describe the trends in birthweight and their association with socioeconomic status in a 10 year birth cohort in Sheffield. METHODS Data for all live singleton births were extracted from the Sheffield Child Development Study (SCDS) database for 1985–94. Enumeration districts (EDs), derived from postcodes, were ranked into deciles by Townsend Deprivation Index (TDI), based on the 1991 census. Birthweight by 500 g group and mean birthweights for the city and by ED decile were calculated by year. χ2 analyses for linear trend were calculated. The proportion of variance in birthweight explained by ED decile and raw TDI score was estimated by year. Absolute risk difference of birthweight <3500 g for the most compared with the least deprived deciles and proportion of births <3500 g statistically “attributable” to social inequality were calculated. RESULTS The mean birthweight for all births increased by 34 g between 1985 and 1994. This difference is largely accounted for by a positive trend in births ⩾3500 g and a negative trend in births of 3000–3499 g. Similar trends were noted across all ED deciles. Around 10% of the variance in birthweight was explained by area deprivation level. Absolute risk difference for births <3500 g was 12.5% for the 10 years (range 8.3–18.4). The proportion of births <3500 g statistically “attributable” to social inequality for the 10 year period was 9.6% (range 4.3–15.5). CONCLUSIONS Despite an overall increase in mean birthweight, large social differences persisted during the study period. An average of 350 births a year were not in the group (⩾3500 g) bestowing most health advantage throughout the life course, as a result of social inequality.

Visual Outcome in 879 Children Treated for Strabismus: Insufficient Accommodation and Vision Deprivation, Deficient Emmetropisation and Anisometropia

Purpose: To identify the effect of infant hypermetropia on residual amblyopia in children remaining after treatment. Materials and Methods: 879 strabismic children had cycloplegic retinoscopy at the age of 6 months and later when strabismus was diagnosed. A total of 26 hypermetropes consistently wore glasses from the age of 6 months, and 305 other hypermetropes had their accommodation periodically assessed by dynamic retinoscopy before strabismus was diagnosed. The relation between the last known visual acuity after treatment and all other clinical findings was analysed using t-tests and regression analysis. Results: Vision less than 6/12 in nonfixing eyes was associated with infantile hypermetropia > +5.0D, and in rare instances in excess of -3.0D of myopia. In hypermetropes only, anisometropia was associated with worse amblyopia. Astigmatism was associated with myopia and low levels of hypermetropia but not with worse vision. The vision of fixing eyes that were hypermetropic was significantly worse than that of emmetropic or myopic eyes. Wearing spectacles from the age of 6 months was associated with better vision in the nonfixing eye. Vision in the nonfixing eye of 19 hypermetropic heterotropes who started wearing glasses between 6 and 18 months of age also was better than that of those who started wearing glasses after 18 months of age. Insufficiency of accommodation was related to the degree of infantile hypermetropia, to worse vision and to failure to emmetropise. Difference in amplitude of accommodation between the eyes was largest in hypermetropes with anisometropia > +1.50 D and was marginally associated with worse vision in microtropes who became anisometropic after infancy. Hypermetropia decreased more in fixing eyes than in nonfixing eyes, thereby causing anisohypermetropia to increase after infancy. This change was most pronounced in hypermetropic microtropes. Conversely, failure of fixing eyes to emmetropise was associated with an increase in their inability to accommodate and heterotropia. Conclusions: On the basis of these findings, severe residual amblyopia in children remaining after treatment could be explained by additional vision deprivation. It can be reduced by starting spectacle correction of hypermetropia before the age of 18 months. Anisometropia seemed the result of deficient emmetropisation.

Elective surgery for aortic abdominal aneurysm: comparison of English outcomes with those elsewhere

Introduction: The aim of this study was to quantify mortality after elective repair of abdominal aortic aneurysm (AAA) in England, and to compare English case fatality rates (CFRs) with those reported in the literature. Patients and methods: English Hospital Episode Statistics (HES) for the financial years 1998/9 to 2001/2, linked to death data, were analysed. A systematic literature search was undertaken to identify studies reporting CFRs after elective AAA surgery. The CFR in England was compared with these studies by using confidence intervals on the CFRs and funnel plot techniques. Results: In the English study, elective repair of AAA was performed on 11 338 patients of whom 771 died within 30 days after surgery (6.8%). The literature search found 66 studies: 34 reported mortality rates that were within the 99% confidence limits of the English rates, 31 below, and one study above. Discussion: The CFR after elective surgical repair in England within 30 days of operation (6.8%) was higher than expected from the literature. Differences between England and other countries in quality of care is one possible explanation for the findings, but other explanations are possible and are discussed.