Long term outcomes in men screened for abdominal aortic aneurysm: prospective cohort study.

OBJECTIVE: To determine whether there is a relation between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm. DESIGN: Prospective cohort study. SETTING: Highland and Western Isles (a large, sparsely populated area of Scotland). PARTICIPANTS: 8146 men aged 65-74. MAIN OUTCOME MEASURES: Morbidity and mortality in relation to presence of abdominal aortic aneurysm and three categories of aortic diameter (≤ 24 mm, 25-29 mm, and ≥ 30 mm). RESULTS: When screened, 414 men (5.1%) had an aneurysm (diameter ≥ 30 mm), 669 (8.2%) an aortic diameter of 25-29 mm, and 7063 (86.7%) an aortic diameter of ≤ 24 mm. The cohort was followed up for a median of 7.4 (interquartile range 6.9-8.2) years. Mortality was significantly associated with aortic diameter: 512 (7.2%) men in the ≤ 24 mm group died compared with 69 (10.3%) in the 25-29 mm group and 73 (17.6%) in the ≥ 30 mm group. The mortality risk in men with an aneurysm or with an aorta measuring 25-29 mm was significantly higher than in men with an aorta of ≤ 24 mm. The increased mortality risk in the 25-29 mm group was reduced when taking confounders such as smoking and known heart disease into account. After adjustment, compared with men with an aortic diameter of ≤ 24 mm, the risk of hospital admission for cardiovascular disease and chronic obstructive pulmonary disease was significantly higher in men with aneurysm and those with aortas measuring 25-29 mm. Men with an aneurysm also had an increased risk of hospital admission for cerebrovascular disease, atherosclerosis, peripheral arterial disease, and respiratory disease. In men with aortas measuring 25-29 mm, the risk of hospital admission with abdominal aortic aneurysm was significantly higher than in men with an aorta of ≤ 24 mm (adjusted hazard ratio 6.7, 99% confidence interval 3.4 to 13.2) and this increased risk became apparent two years after screening. CONCLUSIONS: Men with abdominal aortic aneurysm and those with aortic diameters measuring 25-29 mm have an increased risk of mortality and subsequent hospital admissions compared with men with an aorta diameter of ≤ 24 mm. Consideration should be given to control of risk factors and to rescreening men with aortas measuring 25-29 mm at index scanning.

UK mountain rescue casualties: 2002-2006.

OBJECTIVE: To profile casualties of UK remote and rural sport and recreation rescued by Mountain Rescue Teams (MRTs). METHODS: Anonymised data regarding non-fatal casualties recorded from 1 January 2002 to 31 December 2006 were retrieved from the Mountain Rescue Committees of Scotland and England and Wales. RESULTS: Across the UK there were 6814 incidents involving 7995 people, including 550 fatal incidents. 3398 injured or ill casualties were assisted by rescue teams. Half of those rescued (50.7%) had no medical problems. 3152 casualty reports were available for analysis (Scotland 743, England and Wales 2409). The ages of those assisted ranged from 3 to 104 years, with a male predominance (60.8%). Hillwalking accounted for 75% of mountain rescues. More casualties were injured than ill (77.2% vs 10.4%). The injury reported most often was fracture (58.6%) and the lower extremity was most commonly injured (53%). Multiple injuries were relatively uncommon. The rescue scenarios in England and Wales and in Scotland were broadly similar. MRTs administered medication to more casualties in England and Wales (39.4% vs 14.5%). Helicopters assisted a greater proportion of casualties in Scotland (56.9% vs 40.5%). CONCLUSIONS: Volunteer rescue teams assisted a wide range of casualties including some with serious multiple injuries. The nature of casualty rescues undertaken in Scotland was similar to that in England and Wales. The results have implications for UK-wide rescue team training, medical professionals receiving casualties and for outdoor education safety initiatives.

Effectiveness of policy to provide breastfeeding groups (BIG) for pregnant and breastfeeding mothers in primary care: cluster randomised controlled trial.

OBJECTIVE: To assess the clinical effectiveness and cost effectiveness of a policy to provide breastfeeding groups for pregnant and breastfeeding women. DESIGN: Cluster randomised controlled trial with prospective mixed method embedded case studies to evaluate implementation processes. SETTING: Primary care in Scotland. PARTICIPANTS: Pregnant women, breastfeeding mothers, and babies registered with 14 of 66 eligible clusters of general practices (localities) in Scotland that routinely collect breastfeeding outcome data. INTERVENTION: Localities set up new breastfeeding groups to provide population coverage; control localities did not change group activity. PRIMARY OUTCOME: any breast feeding at 6-8 weeks from routinely collected data for two pre-trial years and two trial years. SECONDARY OUTCOMES: any breast feeding at birth, 5-7 days, and 8-9 months; maternal satisfaction. RESULTS: Between 1 February 2005 and 31 January 2007, 9747 birth records existed for intervention localities and 9111 for control localities. The number of breastfeeding groups increased from 10 to 27 in intervention localities, where 1310 women attended, and remained at 10 groups in control localities. No significant differences in breastfeeding outcomes were found. Any breast feeding at 6-8 weeks declined from 27% to 26% in intervention localities and increased from 29% to 30% in control localities (P=0.08, adjusted for pre-trial rate). Any breast feeding at 6-8 weeks increased from 38% to 39% in localities not participating in the trial. Women who attended breastfeeding groups were older (P<0.001) than women initiating breast feeding who did not attend and had higher income (P=0.02) than women in the control localities who attended postnatal groups. The locality cost was pound13 400 (euro14 410; $20 144) a year. CONCLUSION: A policy for providing breastfeeding groups in relatively deprived areas of Scotland did not improve breastfeeding rates at 6-8 weeks. The costs of running groups would be similar to the costs of visiting women at home. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44857041.

Clinical peripherality: development of a peripherality index for rural health services.

BACKGROUND: The configuration of rural health services is influenced by geography. Rural health practitioners provide a broader range of services to smaller populations scattered over wider areas or more difficult terrain than their urban counterparts. This has implications for training and quality assurance of outcomes. This exploratory study describes the development of a "clinical peripherality" indicator that has potential application to remote and rural general practice communities for planning and research purposes. METHODS: Profiles of general practice communities in Scotland were created from a variety of public data sources. Four candidate variables were chosen that described demographic and geographic characteristics of each practice: population density, number of patients on the practice list, travel time to nearest specialist led hospital and travel time to Health Board administrative headquarters. A clinical peripherality index, based on these variables, was derived using factor analysis. Relationships between the clinical peripherality index and services offered by the practices and the staff profile of the practices were explored in a series of univariate analyses. RESULTS: Factor analysis on the four candidate variables yielded a robust one-factor solution explaining 75% variance with factor loadings ranging from 0.83 to 0.89. Rural and remote areas had higher median values and a greater scatter of clinical peripherality indices among their practices than an urban comparison area. The range of services offered and the profile of staffing of practices was associated with the peripherality index. CONCLUSION: Clinical peripherality is determined by the nature of the practice and its location relative to secondary care and administrative and educational facilities. It has features of both gravity model-based and travel time/accessibility indicators and has the potential to be applied to training of staff for rural and remote locations and to other aspects of health policy and planning. It may assist planners in conceptualising the effects on general practices of centralising specialist clinical services or administrative and educational facilities.

Do people self-reporting information about chronic respiratory disease have corroborative evidence in their general practice medical records? A study of intermethod reliability.

AIMS: To use intermethod reliability to compare self-reported data about chronic respiratory disease and health service utilisation with data contained in general practice medical records. METHODS: Self-reported postal questionnaire information from a small cohort of an age-sex stratified sample of 2318 patients was compared with information contained in their medical records. The agreement between the two sources of information was assessed. RESULTS: The case notes of 115/135 individuals from eight general practices were examined. For self-reported chest injury or operation (kappa, kappa=-0.03), or chronic bronchitis (kappa=0.10), agreement was poor. Agreement for self-reported pleurisy (kappa=0.32), hay fever or rhinitis (kappa=0.40), or eczema or dermatitis (kappa=0.30) was fair; for chronic obstructive pulmonary disease (COPD) or emphysema (kappa=0.56), or heart trouble (kappa=0.54), agreement was moderate; for asthma (kappa=0.78) or pneumonia (kappa=0.62), agreement was good; and for pulmonary tuberculosis (kappa=0.88), agreement was very good. The strength of agreement for information about health service utilisation for respiratory problems ranged from moderate to very good and was good for smoking status. CONCLUSIONS: Although based on small numbers, our results suggest good or very good agreement between self-reported data and general practice medical records for the absence or presence of some respiratory conditions and some types of respiratory-related health care utilisation. Depending on the research question being examined self-reported information may be appropriate.

Health status of professional divers and offshore oil industry workers.

AIMS: To compare the health status of UK professional divers and age-matched non-divers and to contrast offshore divers (OSDs) with non-offshore divers (NOSDs). METHODS: A postal survey sent to 2958 male professional divers, registered with the UK Health & Safety Executive (HSE) before 1991, and 2708 men who had worked in the offshore oil industry in 1990-92 (non-divers). The questionnaire addressed lifestyle, occupation and health status. RESULTS: In all, 56% of divers and 51% of non-divers responded. Three per cent of participants reported ill-health retirement or being off-work on sickness benefit with no difference between groups. Divers were less likely to report asthma or hypertension. Health-related quality of life (SF-12) was within normal limits for both groups but the mental component summary was higher in divers who were also less likely to be receiving medical treatment. Divers were more likely than non-divers to report 'forgetfulness or loss of concentration' (18% versus 6%, OR 3.8, 95% CI 2.7-5.3), musculoskeletal symptoms (41% versus 34%, OR 3.8, 95% CI 2.7-5.3) and 'impaired hearing' (16% versus 11%, OR 1.6, 95% CI 1.2-2.0). These differences were attributable to increased symptom reporting in OSDs and were not present for NOSDs, with the exception of cognitive symptomatology which was commoner in both OSDs (22%, OR 4.8, 95% CI 3.4-6.8) and NOSDs (9%, OR 1.9, 95% CI 1.1-3.3) than in non-divers (6%). CONCLUSIONS: There was increased symptom reporting in OSDs. However, there was no evidence to suggest any major impact on long-term health of UK divers who had started their career before 1991.

Recruitment issues when primary care population clusters are used in randomised controlled clinical trials: climbing mountains or pushing boulders uphill?

Cluster randomised controlled trials for health promotion, education, public health or organisational change interventions are becoming increasingly common to inform evidence-based policy. However, there is little published methodological evidence on recruitment strategies for primary care population clusters. In this paper, we discuss how choosing which population cluster to randomise can impact on the practicalities of recruitment in primary care. We describe strategies developed through our experiences of recruiting primary care organisations to participate in a national randomised controlled trial of a policy to provide community breastfeeding groups for pregnant and breastfeeding mothers, the BIG (Breastfeeding in Groups) trial. We propose an iterative qualitative approach to recruitment; collecting data generated through the recruitment process, identifying themes and using the constant comparative method of analysis. This can assist in developing successful recruitment strategies and contrasts with the standardised approach commonly used when recruiting individuals to participate in randomised controlled trials. Recruiting primary care population clusters to participate in trials is currently an uphill battle in Britain. It is a complex process, which can benefit from applying qualitative methods to inform trial design and recruitment strategy. Recruitment could be facilitated if health service managers were committed to supporting peer reviewed, funded and ethics committee approved research at national level.

Making it Work 2: using a virtual community to focus on rural health issues.

Between 21 and 23 September 2005, over 200 delegates from eight countries gathered in Tromsö, within the Arctic Circle, to discuss challenges and solutions to rural health issues. This conference was a sequel to a previous event entitled 'Making it Work', held in Scotland in 2003, in which it was identified that service delivery in remote and rural areas needed to be innovative to ensure equity. A major aim of this event was to move the debate forward to describe specific examples of practice that could be adopted in participating countries. The delegates included clinicians, managers and administrators, senior policymakers and educationalists, elected local and national politicians, patients and their representatives. In order to focus debate, the organisers provided an outline of a virtual remote community ('Hope'), including some geographic and demographic information, together with four case studies of individual health problems faced by residents of the community. During the introductory session, a short film was shown featuring the 'residents' of this community, introducing delegates to the specific problems they faced. Throughout the conference, delegates were asked to reflect back to how any recommendations made might apply to the citizens of Hope. The clinical scenarios presented included: (1) a 37 year old pregnant woman in labour during adverse weather conditions; (2) a 17 year old island resident with acute psychosis who attempts suicide; (3) an 80 year old woman living alone who suffers a stroke; and (4) a family of four with a complex range of chronic health issues including smoking, alcoholism, diabetes, teenage pregnancy, asthma and depression on a background of deprivation and unemployment. Parallel discussions and workshops focussed on a number of key themes linked to the examples highlighted in the 'Hope' scenario. These included: maternity services; mental health; chronic disease management; health improvement and illness prevention; supporting healthy rural communities; and education for rural health staff. This approach to targeting discussion is valuable in rural health conferences where the participants may be from diverse backgrounds and the issues discussed are multi-faceted.

Geography, private costs and uptake of screening for abdominal aortic aneurysm in a remote rural area.

BACKGROUND: The relationship between geographical location, private costs, health provider costs and uptake of health screening is unclear. This paper examines these relationships in a screening programme for abdominal aortic aneurysm in the Highlands and Western Isles of Scotland, a rural and remote area of over 10,000 square miles. METHODS: Men aged 65-74 (n = 9323) were invited to attend screening at 51 locations in 50 settlements. Effects of geography, deprivation and age on uptake were examined. Among 8,355 attendees, 8,292 completed a questionnaire detailing mode of travel and costs incurred, time travelled, whether accompanied, whether dependants were cared for, and what they would have been doing if not attending screening, thus allowing private costs to be calculated. Health provider (NHS) costs were also determined. Data were analysed by deprivation categories, using the Scottish Indices of Deprivation (2003), and by settlement type ranging from urban to very remote rural. RESULTS: Uptake of screening was high in all settlement types (mean 89.6%, range 87.4-92.6%). Non-attendees were more deprived in terms of income, employment, education and health but there was no significant difference between non-attendees and attendees in terms of geographical access to services. Age was similar in both groups. The highest private costs (median 7.29 pound sterling per man) and NHS screening costs (18.27 pound sterling per man invited) were observed in very remote rural areas. Corresponding values for all subjects were: private cost 4.34 pound sterling and NHS cost 15.72 pound sterling per man invited. CONCLUSION: Uptake of screening for abdominal aortic aneurysm in is remote and rural setting was high in comparison with previous studies, and this applied across all settlement types. Geographical location did not affect uptake, most likely due to the outreach approach adopted. Private and NHS costs were highest in very remote settings but still compared favourably with other published studies.

Is living in a rural area good for your respiratory health? Results from a cross-sectional study in Scotland.

STUDY OBJECTIVES: We aimed to investigate the epidemiology of self-reported chronic respiratory disease throughout Scotland, and to explore the relationship between quality of life and geographic location in those reporting disease. DESIGN: A cross-sectional study. Self-reported data on age, gender, socioeconomic factors, smoking habits, selected illnesses (major respiratory and atopic diseases, and other major conditions), respiratory symptoms, use of medicines and health services, and quality of life were collected using a postal questionnaire. PARTICIPANTS: A total of 4,560 adults registered with 1 of 57 family practices (22 rural and 35 urban) throughout Scotland. RESULTS: The response rate was 60%. Following adjustment for potential confounders, participants from rural areas reported a significantly lower prevalence of any chest illness (adjusted odds ratio [OR], 0.72; 95% confidence interval [CI], 0.58 to 0.91), asthma (adjusted OR, 0.59; 95% CI, 0.46 to 0.76), and eczema/dermatitis (adjusted OR, 0.67; 95% CI, 0.52 to 0.87). Rural location was less likely than urban location to be associated with the reporting of persistent cough and phlegm and different symptoms (types of breathlessness and wheeze) indicative of asthma. No difference in prevalence was found for other respiratory problems. Participants from rural areas reporting COPD or emphysema, or cough or phlegm symptoms had significantly better quality of life scores than their urban counterparts. CONCLUSIONS: In this study, living in a rural area was associated with a lower prevalence of asthma but not other chronic respiratory disorders, and a lower prevalence of some respiratory symptoms (including wheeze). Although the prevalence of COPD or emphysema did not differ between rural and urban areas, rural residency appeared to be associated with better health status among subjects with these conditions.

Injuries to Scottish farmers while tagging and clipping cattle: a cross-sectional survey.

BACKGROUND: Anecdotal reports suggested that farmers were sustaining significant injuries while ear tagging newborn calves or clipping cattle prior to slaughter. AIMS: This national survey was designed for determining the incidence and nature of self-reported injuries to farmers that were sustained while tagging calves and clipping cattle. METHODS: A cross-sectional, anonymous, postal questionnaire survey was sent to all members of the National Farmers Union of Scotland with beef or dairy cattle (n = 4495). RESULTS: In total, 2439 (54%) usable questionnaires were received and 1341 injuries were reported by 591 (24%) respondents. Tagging-related injuries were reported by 297 (12%) respondents. The most commonly described injury was bruising, but lacerations (3%) and fractures (3%) also occurred. Fifty-eight (20%) individuals lost time from work, with a median of 3 days [interquartile range (IQR) = 2-7 days]. Four hundred and eighteen (17%) respondents reported clipping-related injuries. The most common injury was bruising, but lacerations (6%) and fractures (7%) also occurred. Ninety-five (23%) individuals lost time from work, with a median of 4 days (IQR = 2-14 days). Tagging injuries more commonly affected lower limbs and the trunk, while clipping injuries affected the upper limbs. Tagging injuries were associated with working alone, in an open field and with a vehicle nearby, while clipping injuries were associated with working alone, with beef cattle and with younger age. Both types of injury were associated with injuries from livestock in other circumstances. CONCLUSIONS: Tagging calves and clipping cattle prior to slaughter are associated with a significant risk of injury, which may be severe, necessitating treatment and time lost from work. Policy makers, safety advisers and the farming community should reconsider whether these procedures are necessary and whether current guidelines should be modified in order to improve safety.

Annual review of patients with sleep apnea/hypopnea syndrome--a pragmatic randomised trial of nurse home visit versus consultant clinic review.

BACKGROUND: This pragmatic randomised, controlled trial investigated annual review of patients with sleep apnea/hypopnea syndrome (SAHS). Clinical outcomes and costs were compared for consultant clinic review versus specialist nurse home visit. METHOD: One hundred and seventy-four patients were randomised to annual review by consultant clinic appointment or by specialist nurse home visit. SAHS symptoms, Epworth score, hospital anxiety and depression scale (HADS), Short Form-36 (SF-36) and hours of use of constant positive airway pressure (CPAP) were measured before and 3 months after review. The costs and patient preference for review were determined. RESULTS: After review, both groups significantly increased CPAP use (mean (SD) increase: nurse, 0.66 (1.71) h; consultant, 0.45 (1.69) h) and reduced symptom scores (nurse, -2 (7); consultant, -3 (9)), compared to baseline. There were no differences between groups in these improvements, or in HADS or SF-36 scores. Average duration of a nurse home visit, excluding travel time, was 26 (6) min. Total NHS cost per visit was 52.26 UK pounds (49.85) ($83.62 (79.76)), of which 6.57 UK pounds (1.43) ($10.51 (2.29)) reflected time spent with the patient and the remainder was travel cost. Average duration of consultant review was 10 (6) min, total NHS cost 6.21 UK pounds (3.99) ($9.94 (6.38)). However, the cost to the patient of attending the clinic was 23.63 UK pounds (23.21) ($37.81 (37.13)). Patient preference for review was nurse 16%, consultant 19%, and no preference 65%. CONCLUSION: Following annual review, use of CPAP increased and symptoms improved. Outcomes were similar for consultant and nurse led review. Home visits were expensive for the healthcare provider, whereas clinic attendance incurred substantial costs to the patient. The majority of patients would accept nurse review for their sleep apnea management.

Wheezy bronchitis in childhood: a distinct clinical entity with lifelong significance?

BACKGROUND: Historically, clinicians have recognized the existence of the clinical syndrome of childhood wheezy bronchitis. In the late 1960s, children with this syndrome were relabeled as having asthma, and the term wheezy bronchitis was abandoned. In a 1989 study of a cohort that originally had been studied in 1964, we reported that those who had childhood wheezy bronchitis had as adults attained lung function similar to that of healthy control subjects and had less significant symptoms than did those who had experienced childhood asthma, in whom lung function was reduced. In this study, we reexamined these subjects 12 years later to determine whether the improved outcome of the wheezy bronchitis group had been maintained. METHODS: In 2001, we followed up the 283 participants of the 1989 study, who were now aged 45 to 50 years. In interviews, respiratory symptoms and smoking status were assessed. Spirometry was measured. RESULTS: One hundred seventy-seven subjects (63%) completed the study. After adjusting for age, height, gender, socioeconomic status, smoking status, and number of pack-years smoked, the current FEV(1) in the childhood asthma group (mean, 2.45 L; 95% confidence interval, 2.29 to 2.62) was significantly lower than the wheezy bronchitis group (2.78 L, 95% confidence interval, 2.64 to 2.91; p < 0.01) and the control group (2.96 L; 95% confidence interval, 2.83 to 3.1; p < 0.01). The difference between the wheezy bronchitis group and the control subjects was not significant (p = 0.06). Between 1989 and 2001, both the childhood wheezy bronchitis group (p < 0.01) and the childhood asthma group (p = 0.01) had greater declines in FEV(1) than did the control group (asthma group decline, - 0.75 L [95% confidence interval, - 0.66 to - 0.84]; wheezy bronchitis group decline, - 0.75 L [95% confidence interval, - 0.68 to - 0.83]; control group decline, - 0.59 L [95% confidence interval, - 0.52 to - 0.67]). In 2001, the asthma group had more symptoms than did the wheezy bronchitis group (p < 0.01), who were more symptomatic than the control group (p < 0.01). CONCLUSION: Those with childhood wheezy bronchitis, having achieved normal lung function in earlier adulthood, now show a more rapid decline in lung function than did control subjects. If this rate of decline persists, these subjects may develop obstructive airways disease in later life.