Socio-economic inequalities in the incidence of four common cancers: a population-based registry study.

OBJECTIVES: To investigate the relationship between socio-economic circumstances and cancer incidence in Scotland in recent years. STUDY DESIGN: Population-based study using cancer registry data. METHODS: Data on incident cases of colorectal, lung, female breast, and prostate cancer diagnosed between 2001 and 2012 were obtained from a population-based cancer registry covering a population of approximately 2.5 million people in the West of Scotland. Socio-economic circumstances were assessed based on postcode of residence at diagnosis, using the Scottish Index of Multiple Deprivation (SIMD). For each cancer, crude and age-standardised incidence rates were calculated by quintile of SIMD score, and the number of excess cases associated with socio-economic deprivation was estimated. RESULTS: 93,866 cases met inclusion criteria, comprising 21,114 colorectal, 31,761 lung, 23,757 female breast, and 15,314 prostate cancers. Between 2001 and 2006, there was no consistent association between socio-economic circumstances and colorectal cancer incidence, but 2006-2012 saw an emerging deprivation gradient in both sexes. The incidence rate ratio (IRR) for colorectal cancer between most deprived and least deprived increased from 1.03 (95% confidence interval [CI] 0.91-1.16) to 1.24 (95% CI 1.11-1.39) during the study period. The incidence of lung cancer showed the strongest relationship with socio-economic circumstances, with inequalities widening across the study period among women from IRR 2.66 (95% CI 2.33-3.05) to 2.91 (95% CI 2.54-3.33) in 2001-03 and 2010-12, respectively. Breast and prostate cancer showed an inverse relationship with socio-economic circumstances, with lower incidence among people living in more deprived areas. CONCLUSION: Significant socio-economic inequalities remain in cancer incidence in the West of Scotland, and in some cases are increasing. In particular, this study has identified an emerging, previously unreported, socio-economic gradient in colorectal cancer incidence among women as well as men. Actions to prevent, mitigate, and undo health inequalities should be a public health priority.

A retrospective cohort study of the influence of lifestyle factors on the survival of patients undergoing surgery for colorectal cancer.

AIM: Several modifiable and nonmodifiable health-related behaviours are associated with the incidence of colorectal cancer (CRC), but there is little research on their association with survival. This work aimed to investigate possible relationships between modifiable behavioural factors and outcomes on a study cohort of CRC patients undergoing potentially curative surgery. METHOD: A retrospective cohort study was carried out of patients diagnosed with nonmetastatic CRC residing in the NHS Greater Glasgow and Clyde area, UK and undergoing elective curative surgery (January 2011 to December 2012). Data were obtained from the Scottish Cancer Registry, National Scottish Death Records. Preoperative assessment of smoking, alcohol consumption, nurse-measured body mass index (BMI) and exercise levels were recorded, and patients were followed until death or censorship. Survival analysis was carried out and proportional hazards assumptions were assessed graphically using plots and were then formally tested using the PHTEST procedure in stata. RESULT: Of the initial 527 patients, 181 (34%) satisfied the inclusion criteria. The total duration of follow-up was 480 person-years. At the preoperative assessment, 75% of patients were overweight or obese, 10.6% were current smokers, 13.1% recorded excess alcohol consumption and 8.5% had physical difficulty climbing stairs. Age, BMI, histopathological stage and physical capacity all independently affected survival (P < 0.05). Overweight patients [hazard ratio (HR) 2.81] and those who had difficulty climbing stairs (HR 3.31) had a significantly poorer survival. CONCLUSION: This study found evidence that preoperative exercise capacity and BMI are important independent prognostic factors of survival in patients undergoing curative surgery for CRC.

Universal screening for meticillin-resistant Staphylococcus aureus in acute care: risk factors and outcome from a multicentre study.

BACKGROUND: A Health Technology Assessment (HTA) model on effectiveness of meticillin-resistant Staphylococcus aureus (MRSA) screening in Scotland suggested that universal screening using chromogenic agar was the preferred option in terms of effectiveness and cost. AIM: To test the model's validity through a one-year pilot-study. METHOD: A large one-year prospective cohort study of MRSA screening was carried out in six acute hospitals in NHS Scotland, incorporating 81,438 admissions. Outcomes (MRSA colonization and infection rates) were subjected to multivariable analyses, and trends before and after implementation of screening were compared. FINDINGS: The initial colonization prevalence of 5.5% decreased to 3.5% by month 12 of the study (P < 0.0001). Colonization was associated with the number of admissions per patient, specialty of admission, age, and source of admission (home, other hospital or care home). Around 2% of all admissions with no prior history of MRSA infection or colonization tested positive. Those who were screen positive on admission and not previously known positive were 12 times more likely than those who screened negative to develop infection, increasing to 18 times if they were both screen positive and previously known positive. MRSA infections (7.5 per 1000 inpatient-days overall) also reduced significantly over the study year (P = 0.0209). CONCLUSION: The risk factors identified for colonization and infection indicate that a universal clinical risk assessment may have a role in MRSA screening.

Incidence of malignant neoplasms among HIV-infected persons in Scotland.

Among 2574 persons diagnosed with HIV throughout Scotland and observed over the period 1981-1996, cancer incidence compared to the general population was 11 times higher overall; among homosexual/bisexual males, it was 21 times higher and among injecting drug users, haemophiliacs and heterosexuals it was five times higher, mostly due to AIDS-defining neoplasms. However, liver, lung and skin cancers (all non-AIDS-defining) were also significantly increased.

A statistical approach to an outbreak of endophthalmitis following cataract surgery at a hospital in the West of Scotland.

The number of cases of endophthalmitis following cataract surgery caused considerable concern in a West of Scotland hospital throughout 1998 and early 1999. A multi-disciplinary team including infection control nurses, doctors, public health officials,epidemiologists and statisticians was set up to investigate the situation. This paper examines the statistical issues surrounding the investigation. A method based on the Poisson distribution showed that the number of cases was significantly higher than expected. Fisher's Exact Test and Logistic Regression were then applied to the data from two related case control studies. These analyses showed that a higher risk of endophthalmitis was associated with being female, having a vitrectomy or having a previous history of respiratory disease. Finally, a method was devised to enable staff to recognize more quickly when the number of cases of endophthalmitis was becoming higher than expected. The method should find application in other clinical situations where the probability of rare events is known.

Effect of combination therapy on immunologic progression of human immunodeficiency virus at a population level.

There is accumulating evidence from clinical trials and cohort studies that highly active antiretroviral combination therapy is effective at halting immunologic and clinical progression of human immunodeficiency virus (HIV). Its impact at a population level is less well known because the regimes may be difficult to tolerate and compliance poorer. The authors make use of population data for almost all of the HIV-infected people in Scotland in 1997 who were under clinical care and monitor their response to therapy during the first year when these effective treatments became widely available. More than two thirds of the HIV-positive patients were on some form of antiretroviral therapy during the year. The authors show that all treated groups, even those who were on changing regimes, showed net improvement in immunologic status during the year. For the group of patients on triple or quadruple therapy, there was an average increase of more than 100 CD4 cells/mm(3) over the year, with other treatment groups showing more modest, but significant, increases.

Survival after diagnosis of AIDS among adults resident in the United Kingdom in the era of multiple therapies.

The epidemiology of HIV and AIDS in the United Kingdom (UK) has changed markedly since highly active antiretroviral therapy (HAART) was introduced in 1996. HAART including protease inhibitors has considerably improved survival from AIDS diagnosis. The number of deaths of individuals with HIV infection in the UK, reported within 12 months of the end of the year of death, have decreased between 1995 and 1998. Concurrently AIDS diagnoses, reported within 12 months of the end of the year of diagnosis, have declined whilst diagnoses of HIV infection, similarly reported, have risen. Data from 13,689 adult AIDS cases diagnosed up to the end of 1996 were analysed. The overall median survival from AIDS diagnosis to death was 19.3 months. Over 50% of the cases diagnosed in 1996 were alive at the end of the survey therefore median survival exceeds 24 months, the maximum follow up time for the cohort. The opportunity for receiving HAART was modelled in three time periods: pre-multiple therapies (before September 1995), multiple reverse-transcriptase inhibitor therapy available (September 1995 to March 1996), and multiple therapy including protease inhibitors available (April 1996 onwards). Survival rates improved significantly among female heterosexuals and men who have sex with men when multiple therapy including protease inhibitors became available.

Health surveillance of Glasgow medical undergraduates pursuing elective studies abroad (1992-1998).

BACKGROUND: An integral part of the training for many UK medical undergraduates involves a period of elective study abroad. There is concern about the health risks this poses to the students, and uncertainty regarding the responsibility this places on medical schools. METHODS: Annually since 1992, medical undergraduates at Glasgow University have been asked to complete and return a confidential questionnaire on return from their elective studies. This records personal demographic details, the countries visited, and information about illnesses experienced. Analyses were conducted on the students' health experiences, lifestyle, the health precautions taken, and the climates experienced. RESULTS: Global statistics were compiled on 750 respondents. A subset of 267 completed a more extensive, post-1996, questionnaire enabling detailed study of comparative illness rates. A majority took pretravel health advice, visited only one country, stayed for 1 to 2 months, and experienced a tropical climate. Forty-five percent reported symptoms of illness, and alimentary symptoms predominated (77% of those ill). Higher illness rates were reported in those who experienced a hot desert or tropical climate compared with those who did not. There was correlation between taking professional pretravel health advice and exposure to a more hazardous climate. CONCLUSIONS: The attack rate for medical students on electives compares favorably to that for package holidaymakers; similarly the attack rate for students staying in the tropics compared with other travelers. A preexisting health problem did not predispose to a higher attack rate. Attack rates can be minimized by avoiding climatically extreme locations. This surveillance provides a focus of interest to the students, insight on minimizing avoidable health problems, evidences social responsibility by the Medical Faculty, and has the potential for expansion to other medical schools. Current Scottish medical school policies on HIV risk management would be strengthened by a more coordinated approach.

The recent impact of antiretroviral combination therapy on CD4 counts, AIDS and death in HIV-infected persons: routine HIV surveillance in Scotland.

Our aim was to investigate if the clinical benefits of combination antiretroviral therapy recently reported from clinical trials are reproduced in a population-based HIV surveillance scheme. This surveillance scheme is estimated to cover 90% of the HIV-positive population currently under immunological monitoring in Scotland. Our results showed a considerable reduction in new AIDS cases among this group from 107 in 1995 to 59 in 1996 and an estimated 58 in 1997 (allowing for reporting delay). There was a similar fall in deaths from 75 in 1995 to 59 in 1996 and an estimated 24 in 1997. These observations are temporally associated with increasing prescription of antiretroviral therapy in Scotland throughout 1996 and 1997. Examination of those individuals monitored in both 1996 and 1997 showed that from their first CD4 count in 1996 to their first count in 1997 there has been a median gain of 6 CD4 cells/mm3 (95%CI 0-12) compared with a median fall of 27 CD4 cells/mm3 (95%CI -35, -17) for those monitored in both 1995 and 1996. Highest median gains in CD4 cell counts from 1996 to 1997 were seen in those receiving triple or quadruple therapy (median gain 32CD4 cells/mm3). These results are further strengthened by the results of a separate longitudinal analysis showing a highly significant (P < 0.001) effect of treatment on CD4 cell loss with the highest mean CD4 gains being seen in those in triple or quadruple therapy. Our results indicate that the benefits of combination antiretroviral therapy previously seen in clinical trials are being reproduced at a population level. It remains to be seen if these benefits can be sustained in the long term.

Survival of adults with AIDS in the United Kingdom.

Accurate estimates of expected survival times and survival rates of AIDS patients are important both for estimating the prognosis of individuals and for monitoring the progress of the HIV/AIDS epidemic as new treatments are introduced. They are also needed for projecting future numbers of AIDS cases. Data on reported AIDS cases held at the PHLS AIDS Centre at the Communicable Disease Surveillance Centre and the Scottish Centre for Infection and Environmental Health confirmed the time, age, and reporting delay effects identified in earlier analyses of the United Kingdom AIDS database. The duration of survival after AIDS is diagnosed has improved since the epidemic began--median survival was 10.6 months in cases diagnosed before 1987 and has been at least 18.4 months in cases diagnosed each year since then. People who are diagnosed younger live longer--median survival fell from 21.6 months at age 15 to 29 to 12.6 months at age 45 or over. Delay in reporting AIDS cases adversely affects survival estimates for cases reported in recent years. Survival was longer in cases reported over a year after diagnosis of AIDS--23.7 months compared with 16.9 months in those reported less than a year after diagnosis. The experience of the hospital, measured by its cumulative AIDS caseload, was an important factor in the survival of men who have sex with men presenting with Kaposi's sarcoma alone or 'other' diagnoses--survival was shorter for cases reported from smaller centres. Men who have sex with men with Pneumocystis carinii pneumonia alone or other opportunistic infections alone who were known to be HIV positive before being diagnosed with AIDS had a shorter survival after being diagnosed than those who were unaware of their HIV infection. This supports the hypothesis that treatment for HIV infection and prophylaxis may extend the period before AIDS develops but reduce the period between developing AIDS and dying.

United Kingdom AIDS survival in adults.

OBJECTIVE: To examine the impact of age, year and region of AIDS diagnosis on early (up to 12 months) and late survival of AIDS patients in different exposure categories; to describe the hazard pattern from 12 months after AIDS diagnosis. PATIENTS: A total of 4577 UK adult AIDS diagnoses to the end of 1991 in men who have sex with men, 273 AIDS cases in injecting drug users, 411 AIDS patients infected by blood products, and 535 other adult AIDS cases, mainly ascribed to heterosexual transmission. Deaths have been recorded for 4739 of these 5796 AIDS patients. RESULTS: The influence of calendar year and region of AIDS diagnosis on survival were short-term, for the most part operative only within the first year of follow-up. The monthly death-rate was roughly constant from 12 to 48 months post-AIDS [pooled estimate, 0.055 with 95% confidence interval (CI), 0.053-0.057] but was more than halved for 4-year survivors (pooled estimate, 0.022; 95% CI, 0.017-0.027). About 7% of AIDS cases diagnosed in 1990-1991 survive for at least 48 months. Survival after AIDS diagnosis shortens with advancing age at AIDS diagnosis: the relative hazard per decade of age (1.35; 95% CI, 1.29-1.41 in the first year after AIDS) is significantly greater (P < 0.001) in the first year after AIDS diagnosis than from 12 to 48 months (1.19; 95% CI, 1.13-1.25 in the second epoch). CONCLUSIONS: The influence of covariates, including age, is strongest in the first year of follow-up after AIDS diagnosis. Monthly death-rate is roughly constant at 0.055 from 12 to 48 months post-AIDS and at 0.022 thereafter.

Improved survival from diagnosis of AIDS in adult cases in the United Kingdom and bias due to reporting delays.

OBJECTIVE: To measure developments in survival patterns among United Kingdom adult AIDS cases. DESIGN: A follow-up survey of cases reported voluntarily to the national surveillance schemes was undertaken to obtain up-to-date information on vital status. METHODS: All reporting clinicians who had a current AIDS patient not known to have died whose AIDS-defining illness was diagnosed before the end of September 1990 were contacted. A total of 3984 cases were included in the analysis. RESULTS: An extra third of deaths other than those reported through routine channels were ascertained by follow-up. Median survival for patients diagnosed before and after the end of 1986 increased from 15 to 18 months for men who had sex with men presenting with Kaposi's sarcoma, from 10 to 19 months for other men who had sex with men and from 7 to 16 months for all others. Improvement in survival was greatest in the first 3 months. One-third of patients have been surviving 2 years or more. Factors observed with independent effects on improved survival are recent diagnosis, younger age and larger cumulative AIDS case load of reporting centre. HIV encephalopathy and other central nervous system symptoms may be associated with poorer survival. CONCLUSIONS: Survival patterns have been changing and generally improving. Average survival for very recent cohorts tends to be underestimated because longer survival has been observed in patients for whom there is a longer delay between AIDS diagnosis and report to the Communicable Disease Surveillance Centre. Information on mortality is improved by active follow-up.

Extracranial insults and outcome in patients with acute head injury--relationship to the Glasgow Coma Scale.

Hypoxia and hypotension are extracranial insults known to have an adverse effect on the outcome of patients with acute head injury. Arterial oxygen tension, blood pressure and the Glasgow Coma Score on admission of 67 patients seen over a 6-month period were correlated with the outcome at 6 months. With a given level of consciousness the presence of an extracranial insult resulted in a worse outcome than would be predicted. The combination of hypoxia and hypotension was uniformly fatal as was the presence of severe respiratory dysfunction.