Robert Lancashire

Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study

BACKGROUND Accurate data for prevalence rates for heart failure due to various causes, and for left-ventricular systolic dysfunction in all adults are unavailable. Our aim was to assess prevalence of left-ventricular systolic dysfunction and heart failure in a large representative adult population in England. METHODS Of 6286 randomly selected patients aged 45 years and older, 3960 (63%) participated in the study. They came from 16 randomly selected general practices. We assessed patients by history and examination, electrocardiography, and echocardiography. Prevalence of left-ventricular systolic dysfunction (defined as ejection fraction <40%) and heart failure was calculated for the overall population on the basis of strict criteria and, when necessary, adjudication by a panel. FINDINGS Left-ventricular systolic dysfunction was diagnosed in 72 (1.8% [95% CI 1.4-2.3]) participants, half of whom had no symptoms. Borderline left-ventricular function (ejection fraction 40-50%) was seen in 139 patients (3.5% [3.0-4.1]). Definite heart failure was seen in 92 (2.3%, [1.9-2.8]) and was associated with an ejection fraction of less than 40% in 38 (41%) patients, atrial fibrillation in 30 (33%), and valve disease in 24 (26%). Probable heart failure was seen in a further 32 (0.8% [0.6-1.1]) patients. In total, 124 (3.1% [2.6-3.7]) patients aged 45 years or older had definite or probable heart failure. INTERPRETATION Heart failure is often misdiagnosed or underdiagnosed in primary care. Our results suggest that assessment of left-ventricular function in patients with suspected heart failure could lead to more effective diagnosis and treatment of this disorder.

Effect of anti-inflammatory drugs on overall risk of common cancer: case-control study in general practice research database.

Abstract Objective: To examine whether anti-inflammatory drug treatment protects against the commoner cancers in the United Kingdom. Design: Case-control study using the general practice research database. Setting: Practices throughout United Kingdom providing data to the database. Subjects: Patients who had a first diagnosis of five gastrointestinal (oesophagus, stomach, colon, rectum, and pancreas) cancers and four non-gastrointestinal (bladder, breast, lung, and prostate) cancers in 1993–5 for whom prescription data were available for the at least the previous 36 months. Each case was matched for age, sex, and general practice with three controls. Main outcome measure: Risk of cancer. Results: In 12 174 cancer cases and 34 934 controls overall risk of the nine cancers was not significantly reduced among those who had received at least seven prescriptions in the 13–36 months before cancer diagnosis (odds ratio 0.98, 95% confidence interval 0.89 to 1.07). Findings were nevertheless compatible with protective effects from anti-inflammatory drugs against cancers of the oesophagus (0.64, 0.41 to 0.98), stomach (0.51, 0.33 to 0.79), colon (0.76, 0.58 to 1.00), and rectum (0.75, 0.49 to 1.14) with dose related trends. The risk of pancreatic cancer (1.49, 1.02 to 2.18) and prostatic cancer (1.33, 1.07 to1.64) was increased among patients who had received at least seven prescriptions, but the trend was dose related for only pancreatic cancer. Conclusions: Anti-inflammatory drugs may protect against oesophageal and gastric cancer as well as colon and rectal cancer. The increased risks of pancreatic and prostatic cancer could be due to chance or to undetected biases and warrant further investigation.

Childhood cancer and parental use of tobacco: deaths from 1953 to 1955

Parental smoking data have been reabstracted from the interview records of the Oxford Survey of Childhood Cancers (deaths from 1971 to 1976). Reported smoking habits for the parents of 2587 children who died with cancer were compared with similar information for the parents of 2587 healthy controls (matched pairs analysis). Maternal daily consumption of cigarettes and paternal use of pipes or cigars were unimportant, but there was a statistically significant positive trend between paternal daily consumption of cigarettes and the risk of childhood cancer (P < 0.001). This association could not be explained by maternal smoking, social class, parental ages at the birth of the survey child, sibship position or obstetric radiography. Relations between maternal consumption of cigarettes and birth weights suggested that (maternal) smoking data were equally reliable for case and control subjects. About 14% of all childhood cancers in this series could be attributable to paternal smoking. These data were combined with smoking data from two previously published reports from the Oxford Survey (deaths from 1953 to 1955, deaths from 1977 to 1981) to obtain further information on risks for different types of cancer and different ages at onset of disease. Paternal cigarette smoking emerged as a potential risk factor both for the generality of childhood cancer and for all ages at onset.

Obstetric practice and faecal incontinence three months after delivery

Objective To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum.

Cluster randomised controlled trial of expert system based on the transtheoretical (“stages of change”) model for smoking prevention and cessation in schools

Abstract Objectives: To examine whether a year long programme based on the transtheoretical model of behaviour change, incorporating three sessions using an expert system computer program and three class lessons, could reduce the prevalence of teenage smoking. Design: Cluster randomised trial comparing the intervention to a control group exposed only to health education as part of the English national curriculum. Setting: 52 schools in the West Midlands region. Participants: 8352 students in year 9 (age 13-14 years) at those schools. Main outcome measures: Prevalence of teenage smoking 12 months after the start of the intervention. Results: Of the 8352 students recruited, 7444 (89.1%) were followed up at 12 months. The intention to treat odds ratio for smoking in the intervention group relative to control was 1.08 (95% confidence interval 0.89 to 1.33). Sensitivity analysis for loss to follow up and adjustment for potential confounders did not alter these findings. Conclusions: The smoking prevention and cessation intervention based on the transtheoretical model, as delivered in this trial, is ineffective in schoolchildren aged 13-14. Key messages The transtheoretical model proposes that individuals move through a series of stages in behaviour change A computer programme gave 13 and 14 year old school students tailored information about what stage they were in and what to do to move to the next stage Students given this information were no more likely to move stage, refrain from smoking, or stop smoking than those exposed to ordinary classroom health education There is no evidence that the computerised expert system based on the transtheoretical model is effective in smoking prevention and cessation

New postnatal urinary incontinence : obstetric and other risk factors in primiparae

Objective  To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth.

Persistent urinary incontinence and delivery mode history: a six-year longitudinal study.

Objective  To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery.

What influences the uptake and early cessation of breast feeding

OBJECTIVE To examine obstetric, maternal and social factors associated with the uptake and early cessation of breast feeding and womens reasons for altering from breast to bottle feeding. DESIGN Women who responded to a postal questionnaire on long-term postpartum health were contacted and asked to participate in a home-based interview. In addition to health problems, the interview obtained information on baby feeding and a number of social factors. Women were also asked to complete the Edinburgh Postnatal Depression Scale (EPDS). Obstetric and maternal data were obtained from maternity records. SETTING Deliveries from a large maternity hospital in Birmingham. PARTICIPANTS 906 women were interviewed at a mean of 45 weeks after delivery. FINDINGS 63% of the women said they had breast fed, but 40% of these stopped within three months of delivery. Many of the women gave physical problems with lactation as reasons for stopping. The factors found to be predictors of early cessation were: return to work within three months of birth; regular childcare support from other female relatives, and a high EPDS score. Non-initiation of breast feeding was predicted by a different set of factors: multiparity; general anaesthetic (GA); and unmarried status. DISCUSSION AND CONCLUSION Despite evidence of the benefits of breast feeding, this remains an unacceptable long-term option for many women, and for over one-third it is never attempted. Factors within the womans social environment were found to influence early cessation. Women who had a GA during or immediately following labour and delivery were less likely to initiate breast feeding. IMPLICATIONS FOR PRACTICE If breast-feeding incidence and duration are to increase, more attention should be paid to establishing early, successful breast feeding and countering the negative influences of factors within the social environment.

Faecal incontinence and mode of first and subsequent delivery: a six-year longitudinal study

Objective  To investigate the prevalence of persistent and long term postpartum faecal incontinence and associations with mode of first and subsequent deliveries.

The risk of colorectal cancer with symptoms at different ages and between the sexes: a case-control study

BackgroundColorectal cancer is generally diagnosed following a symptomatic presentation to primary care. Although the presenting features of the cancer are well described, the risks they convey are less well known. This study aimed to quantify the risk of cancer for different symptoms, across age groups and in both sexes.MethodsThis was a case-control study using pre-existing records in a large electronic primary care database. Cases were patients aged 30 years or older with a diagnosis of colorectal cancer between January 2001 and July 2006, matched to seven controls by age, sex and practice. All features of colorectal cancer recorded in the 2 years before diagnosis were identified. Features independently associated with cancer were identified using multivariable conditional logistic regression, and their risk of cancer quantified.ResultsWe identified 5477 cases, with 38,314 age, sex and practice-matched controls. Six symptoms and two abnormal investigations (anaemia and microcytosis) were independently associated with colorectal cancer. The positive predictive values of symptoms were: rectal bleeding, positive predictive value for a male aged ≥ 80 years 4.5% (95% confidence interval 3.5, 5.9); change in bowel habit 3.9% (2.8, 5.5); weight loss 0.8% (0.5, 1.3); abdominal pain 1.2% (1.0, 1.4); diarrhoea 1.2% (1.0, 1.5) and constipation 0.7% (0.6, 0.8). Positive predictive values were lower in females and younger patients. Only 27% of patients had reported either of the two higher risk symptoms.ConclusionMost symptomatic colorectal cancers present with only a low-risk symptom. There is a need to find a method of identifying those at highest risk of cancer from the large number presenting with such symptoms.