Staging quality is related to the survival of women with endometrial cancer: a Scottish population based study. Deficient surgical staging and omission of adjuvant radiotherapy is associated with poorer survival of women diagnosed with endometrial cancer in Scotland during 1996 and 1997.

The association between treatment variation and survival of women with endometrial cancer was investigated. A retrospective cohort based upon the complete Scottish population registered on in-patient and day-case hospital discharge data (Scottish Morbidity Record-1) and cancer registration (Scottish Morbidity Record-6) coded C54 and C55 in ICD10, between 1st January 1996 to 31st December 1997 were analysed. Seven hundred and three patients who underwent surgical treatment out of 781 patients that were diagnosed with endometrial cancer in Scotland during 1996 and 1997. The overall quality of surgical staging was poor. The quality of staging was related to both the year that the surgeon passed the Member of the Royal College of Obstetricians and Gynaecologists examination and also to 'specialist' status but was not related to surgeon caseload. Two clinically important prognostic factors were found to be associated with survival; whether the International Federation of Obstetrics and Gynaecology stage was documented, RHR=2.0 (95% CI=1.3 to 3.1) and also to the use of adjuvant radiotherapy, RHR=2.2 (95% CI=1.5 to 3.5). The associations with survival were strongest in patients with advanced disease, International Federation of Obstetrics and Gynaecology stages 1C through to stage 3. Deficiencies in staging and variations in the use of adjuvant radiotherapy represent a possible source of avoidable mortality in patients with endometrial cancer. Consequently, there should be a greater emphasis on improving the overall quality of surgical staging in endometrial cancer.

The national health demonstration projects.

The White Paper Towards a Healthier Scotland pledged 15 million Pounds to support four national health demonstration projects to lead the way in achieving sustained improvement in child health, young people's sexual health, coronary heart disease and cancer. The Starting Well project aims to demonstrate that child health in Glasgow can be improved by a programme of activities which both supports families and provides them with access to enhanced community-based resources. The Healthy Respect project aims to help young people in Lothian develop a positive attitude to their own sexuality and that of others, and a healthy respect for their partners, in order to reduce unplanned teenage pregnancies and sexually transmitted infections. The Have a Heart Paisley project is targeting coronary heart disease among the population of Scotland's largest town. The Cancer Challenge project is piloting a screening programme in the North East of Scotland for the detection of colorectal cancer. Though each project has specific objectives, appropriate to its own topic, all share underlying principles. The projects will act as test beds for action and a learning resource for the rest of Scotland.

Low dependency residents in private nursing homes in Glasgow.

OBJECTIVES: To investigate why nursing home care had been recommended for elderly people who were assessed subsequently as being of low dependency. DESIGN: Examination of community care assessment documentation for low dependency residents to assess reasons for recommending nursing home care; comparison of these with data from a subsequent SCRUGs (Scottish Care Resource Utilisation Groups) assessment. SETTING AND SUBJECTS: Three hundred and four residents within eight private nursing homes in Glasgow. RESULTS: Twenty six percent of the residents were described as being of low dependency. Of these, 44% had dementia and 6% personal care needs alone; 29% had medical problems which required nursing input, but not necessarily to a level requiring nursing home care. Information in the community care assessment often described a higher level of need than that identified subsequently. From the information given in the medical component of the community care assessment it was often unclear why the decision to recommend nursing home care was made. CONCLUSION: Admission to nursing homes may be encouraged by over-emphasiZing care requirements, by placing emphasis on safety rather than independence and by inadequate recording of information. Elderly people who cannot remain at home need improved assessment procedures, better understanding of their needs and a wider range of accommodation options.

Regional variation in incidence and case fatality of myocardial infarction among young women in England, Scotland and Wales.

OBJECTIVES: To examine the regional variation in incidence and case fatality of myocardial infarction among young women. DESIGN: Cross sectional survey, using population based incidence data. SETTING: England, Scotland and Wales. SUBJECTS: Subjects were women aged 16-44 with a diagnosis of myocardial infarction between 1 October 1993 and 15 October 1995. OUTCOME MEASURES: Incidence of myocardial infarction per 100,000 women years, with case fatality as a percentage of total cases. RESULTS: Incidence of myocardial infarction rose steeply from age 33 upwards, (maximum = 20.2 cases per 100,000 women years at age 44). The adjusted incidence rate for myocardial infarction was 3.7 (95% CI 3.2, 4.2) times greater in Scotland than in southern England. In contrast, case fatality was significantly lower in Scotland: 18.5% (95% CI 13.1%, 25.0%), compared with 31.0% (95% CI 25.9%, 36.0%) in southern England. CONCLUSIONS: The incidence of myocardial infarction varied widely within the United Kingdom. Case fatality variation may reflect differences in ambulance response, or in diagnostic acumen, within the regions.

Risk of myocardial infarction in young female smokers.

OBJECTIVES: To determine the extent of risk of myocardial infarction from cigarette smoking in young women, and to examine the relation of smoking with other putative risk factors. DESIGN: Community based case control study. SETTING: England, Scotland, and Wales. PATIENTS: Women (n = 448) between 16 and 44 years old with a diagnosis of incident myocardial infarction between 1 October 1993 and 16 October 1995. Controls (n = 1728) were age and general practice matched women without a diagnosis of myocardial infarction. OUTCOMES MEASURES: Odds ratios for risk of myocardial infarction associated with smoking and other risk factors. RESULTS: Odds ratios for myocardial infarction in smokers versus non-smokers showed a strong dose response, from 2.47 (95% confidence interval (CI) 1.12 to 5.45) in smokers of 1-5 cigarettes per day to 74.6 (95% CI 33.0 to 169) in smokers of >/= 40 cigarettes per day. There was no interaction of smoking with use of oral contraceptives, but there were additive risks with other clinical risk factors such as hypertension and diabetes. It is estimated that if all women aged 16-44 years were able to stop smoking, 400 cases of myocardial infarction per annum (of whom 112 would die) would be prevented. CONCLUSIONS: In young women the risk of myocardial infarction from smoking was considerable, and heavy smokers with other risk factors were especially at risk.

Oral contraceptives and myocardial infarction: results of the MICA case-control study.

OBJECTIVES: To determine the association between myocardial infarction and use of different types of oral contraception in young women. DESIGN: Community based case-control study. Data from interviews and general practice records. SETTING: England, Scotland, and Wales. PARTICIPANTS: Cases (n=448) were recruited from women aged between 16 and 44 who had suffered an incident myocardial infarction between 1 October 1993 and 16 October 1995. Controls (n=1728) were women without a diagnosis of myocardial infarction matched for age and general practice. MAIN OUTCOME MEASURES: Odds ratios for myocardial infarction in current users of all combined oral contraceptives stratified by their progestagen content compared with non-users; current users of third generation versus second generation oral contraceptives. RESULTS: The adjusted odds ratio for myocardial infarction was 1.40 (95% confidence interval 0.78 to 2. 52) for all combined oral contraceptive users, 1.10 (0.52 to 2.30) for second generation users, and 1.96 (0.87 to 4.39) for third generation users. Subgroup analysis by progestagen content did not show any significant difference from 1, and there was no effect of duration of use. The adjusted odds ratio for third generation users versus second generation users was 1.78 (0.66 to 4.83). 87% of cases were not exposed to an oral contraceptive, and 88% had clinical cardiovascular risk factors or were smokers, or both. Smoking was strongly associated with myocardial infarction: adjusted odds ratio 12.5 (7.29 to 21.5) for smoking 20 or more cigarettes a day. CONCLUSIONS: There was no significant association between the use of oral contraceptives and myocardial infarction. The modest and non-significant point estimates for this association have wide confidence intervals. There was no significant difference between second and third generation products.

PIP: The association between myocardial infarction and use of oral contraceptives (OCs) was investigated in a case-control study conducted in England, Scotland, and Wales. 448 women 16-44 years old who had suffered an incident myocardial infarction during 1991-95 were identified from general practice records and matched by age and general practice with 1728 healthy controls. 85% of cases were not taking OCs in the 3 months before their myocardial infarction. The adjusted odds ratio (OR) for myocardial infarction was 1.40 (95% confidence interval [CI], 0.78-2.52) for all combined OC users, 1.10 (95% CI, 0.52-2.30) for users of second-generation formulations, and 1.96 (95% CI, 0.87-4.39) for third-generation OCs. Subgroup analysis by progestogen content did not show any significant difference from 1, and there was no effect of duration of OC use. 88% of cases had clinical cardiovascular risk factors or were smokers, or both. The adjusted OR for third-generation vs. second-generation OC users was 1.78 (95% CI, 0.66-4.83). The adjusted OR was 12.5 (95% CI, 7.29-21.5) among women who smoked 20 or more cigarettes a day. These findings indicate that OCs, including third-generation formulations, do not increase a woman's risk of myocardial infarction. Women who are concerned about their cardiovascular health should be urged to stop smoking, however.

Oral contraceptives and thrombosis.

PIP: Recent studies have identified an increased risk of venous thromboembolism associated with use of third-generation oral contraceptives (OCs). Use of these newer formulations has been estimated to cause an excess of 10 deaths/year in the UK. The possibility has been raised, however, that prescribing bias and confounding by duration of OC use and other personal risk factors accounts for the difference in the risk of venous thromboembolism between second- and third-generation OCs. Other studies have identified an increased risk of myocardial infarction and stroke in OC users, including users of low-dose formulations, but this risk is almost exclusively limited to older women who smoke or have other cardiovascular risk factors. The interpretation of all such studies on OC side effects should take into account that the absolute risk of an adverse thrombotic event while taking OCs is small. This risk appears to be affected far more by factors such as smoking, age, hypertension, and familial disorders than the type of progestagen contained in the OC.^ieng

Myocardial infarction and oral contraceptives, a retrospective case control study in England and Scotland ('MICA' Study).

Recent studies have shown that modern (third generation), oral contraceptives (OC) are associated with an increased incidence of venous thromboembolic disease compared to older (second generation), OC. It is not known, however, whether this association is also true for arterial thrombosis, in particular myocardial infarction. In fact, it has been suggested that third generation OC may even be protective against myocardial infarction (MI), compared to second generation OC. The protocol for a multicentre case-control study, involving the whole of England and Scotland, is described. Cases will be female patients aged 16-44 years, who suffered an MI between 1.10.93 and 1.10.95. Controls will be drawn from the community, using the GP list, to which the case belonged. Odds ratios will be calculated primarily to compare current users of third generation OC with current users of second generation OC.

The neonatal consequences and neonatal cost of reducing the number of embryos transferred following IVF.

This clinical audit project examined the effects of change of policy between 1990 and 1993 transferring an average two (maximum three for particular cases) embryos to women undergoing IVF in the West of Scotland programme. All women who achieved clinical pregnancy in 1990 (92 women) and 1993 (93 women) as a result of the IVF programme were included in the study. The hospital records of women via the programme were analysed. The results of the study showed that there was a significant reduction in the rate of multiple pregnancy, preterm birth and low birth weight babies in the 1993 group (new policy). The cost of neonatal intensive care in 1993 for babies born following IVF was about nine times lower than that in 1990 (old policy). This study concluded that a policy of transferring two embryos (or three for particular cases) to women in an IVF programme, had improved the perinatal outcome and reduced the cost of the neonatal service for those babies.