Does lesion type or severity predict outcome of therapy for horses with equine glandular gastric disease? - A retrospective study.

BACKGROUND: Equine glandular gastric disease (EGGD) is a common condition of the horse. Misoprostol is reported to be superior to oral omeprazole and sucralfate for treatment. Long-acting intramuscular injectable omeprazole (LAIOMEP) is a novel treatment shown to be effective in a small population. OBJECTIVES: This study aimed to determine LAIOMEP efficacy compared to misoprostol and oral omeprazole and identify characteristics that predict treatment outcome. METHODS: All horses that underwent gastroscopy between 2012 and 2019 were reviewed. Lesions were characterised by 4 blinded observers, all of whom are diplomates in equine internal medicine, using established descriptors from the ECEIM consensus statement and subjective severity. Treatment outcome was ranked as worsened, improved or healed. Consensus lesion type, lesion severity and treatment choice were compared to outcome and data screened using univariate analysis (chi-squared) to determine whether each predicted outcome. Lesion types where univariate analysis predicted a trend (p<0.2) were included in a multiple-regression analysis to identify predictors of outcome irrespective of treatment. RESULTS: Only severity significantly predicted final outcome (p = 0.025) with severe lesions being more likely to improve. Treatment choice did not significantly predict outcome. Overall healing rate was 29% (24 horses), and 43% (44 horses) improved. Treatment healing rates were 23% (10), 12% (7) and 27% (7) for LAIOMEP, misoprostol and oral omeprazole, respectively, with improvement in 69% (14), 76% (21) and 61% (9). 64% of the latter group received sucralfate. Worsening occurred in 7% (6). Treatment length varied with a median of 4 weeks (range 4-20 weeks). CONCLUSIONS: This study showed poorer therapy outcome compared to previous studies. The only initial lesion descriptor to predict outcome was severity and treatment choice did not affect outcome.

BEVA primary care clinical guidelines: Analgesia.

Primary care guidelines provide a reference point to guide clinicians based on a systematic review of the literature, contextualised by expert clinical opinion. These guidelines develop a modification of the GRADE framework for assessment of research evidence (vetGRADE) and applied this to a range of clinical scenarios regarding use of analgesic agents. Key guidelines produced by the panel included recommendations that horses undergoing routine castration should receive intratesticular local anaesthesia irrespective of methods adopted and that horses should receive NSAIDs prior to surgery (overall certainty levels high). Butorphanol and buprenorphine should not be considered appropriate as sole analgesic for such procedures (high certainty). The panel recommend the continuation of analgesia for 3 days following castration (moderate certainty) and conclude that phenylbutazone provided superior analgesia to meloxicam and firocoxib for hoof pain/laminitis (moderate certainty), but that enhanced efficacy has not been demonstrated for joint pain. In horses with colic, flunixin and firocoxib are considered to provide more effective analgesia than meloxicam or phenylbutazone (moderate certainty). Given the risk of adverse events of all classes of analgesic, these agents should be used only under the control of a veterinary surgeon who has fully evaluated a horse and developed a therapeutic, analgesic plan that includes ongoing monitoring for such adverse events such as the development of right dorsal colitis with all classes of NSAID and spontaneous locomotor activity and potentially ileus with opiates. Finally, the panel call for the development of a single properly validated composite pain score for horses to allow accurate comparisons between medications in a robust manner.

Short-term and long-term outcomes in 133,429 emergency patients admitted with angina or myocardial infarction in Scotland, 1990-2000: population-based cohort study.

OBJECTIVE: To analyse short- and long-term outcomes and prognostic factors in a large population-based cohort of unselected patients with a first emergency admission for suspected acute coronary syndrome between 1990 and 2000 in Scotland. METHODS: All first emergency admissions for acute myocardial infarction (AMI) and all first emergency admissions for angina (the proxy for unstable angina) between 1990 and 2000 in Scotland (population 5.1 million) were identified. Survival to five years was examined by Cox multivariate modelling to examine the independent prognostic effects of diagnosis, age, sex, year of admission, socioeconomic deprivation and co-morbidity. RESULTS: In Scotland between 1990 and 2000, 133,429 individual patients had a first emergency admission for suspected acute coronary syndrome: 96 026 with AMI and 37,403 with angina. After exclusion of deaths within 30 days, crude five-year case fatality was similarly poor for patients with angina and those with AMI (23.9% v 21.6% in men and 23.5% v 26.0% in women). The longer-term risk of a subsequent fatal or non-fatal event in the five years after first hospital admission was high: 54% in men after AMI (53% in women) and 56% after angina (49% in women). Event rates increased threefold with increasing age and 20-60% with different co-morbidities, but were 11-34% lower in women. CONCLUSIONS: Longer-term case fatality was similarly high in patients with angina and in survivors of AMI, about 5% a year. Furthermore, half the patients experienced a fatal or non-fatal event within five years. These data may strengthen the case for aggressive secondary prevention in all patients presenting with acute coronary syndrome.

Modelling of output factors for conformal megavoltage X-ray beams.

A method is described for calculating the output from conformally shaped megavoltage X-ray beams. The model has been developed for Varian accelerators but is shown to work for accelerators from another manufacturer. The use of dynamic wedging and both static and dynamic multileaf collimated beams are included in the model. For any linear accelerator, the data required are a set of measured output factors for square beams, an in-air profile and a limited number of readily available parameters defining the geometry of the head of the accelerator. The three components of the output, namely primary, head scatter and phantom scatter are modelled and calculated individually for any point in a beam. An optimization procedure is developed that automatically determines the eight parameters required to model an accelerator in order for these calculations to be performed. The performance of the method is demonstrated for shaped beams using asymmetric and multileaf collimation, both with and without wedging, and for a range of beam energies. The model has been incorporated into a computer program that is used clinically.

Why is mortality higher in Scotland than in England and Wales? Decreasing influence of socioeconomic deprivation between 1981 and 2001 supports the existence of a 'Scottish Effect'.

OBJECTIVES: To determine the degree to which changing patterns of deprivation in Scotland and the rest of Great Britain between 1981 and 2001 explain Scotland's higher mortality rates over that period. DESIGN: Cross-sectional analyses using population and mortality data from around the 1981, 1991 and 2001 censuses. SETTING: Great Britain (GB). PARTICIPANTS: Populations of Great Britain enumerated in the 1981, 1991 and 2001 censuses. MAIN OUTCOME MEASURES: Carstairs deprivation scores derived for wards (England and Wales) and postcode sectors (Scotland). Mortality rates adjusted for age, sex and deprivation decile. RESULTS: Between 1981 and 2001 Scotland became less deprived relative to the rest of Great Britain. Age and sex standardized all-cause mortality rates decreased by approximately 25% across Great Britain, including Scotland but mortality rates were on average 12% higher in Scotland in 1981 rising to 15% higher in 2001. While over 60% of the excess mortality in 1981 could be explained by differences in deprivation profile, less than half the excess could be explained in 1991 and 2001. After adjusting for age, sex and deprivation, excess mortality in Scotland rose from 4.7% (95% CI: 3.9% to 5.4%) in 1981 to 7.9% (95% CI: 7.2% to 8.7%) in 1991 and 8.2% (95% CI: 7.4% to 9.0%) in 2001. All deprivation deciles showed excess indicating that populations in Scotland living in areas of comparable deprivation to populations in the rest of Great Britain always had higher mortality rates. By 2001 the largest excesses were found in the most deprived areas in Scotland with a 17% higher mortality rate in the most deprived decile compared to similarly deprived areas in England and Wales. Excess mortality in Scotland has increased most among males aged <65 years. CONCLUSIONS: Scotland's relative mortality disadvantage compared to the rest of Great Britain, after allowing for deprivation, is worsening. By 1991 measures of deprivation no longer explained most of the excess mortality in Scotland and the unexplained excess has persisted during the 1990s. More research is required to understand what is causing this 'Scottish effect'.

National survey of the prevalence, incidence, primary care burden, and treatment of heart failure in Scotland.

OBJECTIVE: To examine the epidemiology, primary care burden, and treatment of heart failure in Scotland, UK. DESIGN: Cross sectional data from primary care practices participating in the Scottish continuous morbidity recording scheme between 1 April 1999 and 31 March 2000. SETTING: 53 primary care practices (307,741 patients). SUBJECTS: 2186 adult patients with heart failure. RESULTS: The prevalence of heart failure in Scotland was 7.1 in 1000, increasing with age to 90.1 in 1000 among patients > or = 85 years. The incidence of heart failure was 2.0 in 1000, increasing with age to 22.4 in 1000 among patients > or = 85 years. For older patients, consultation rates for heart failure equalled or exceeded those for angina and hypertension. Respiratory tract infection was the most common co-morbidity leading to consultation. Among men, 23% were prescribed a beta blocker, 11% spironolactone, and 46% an angiotensin converting enzyme inhibitor. The corresponding figures for women were 20% (p = 0.29 versus men), 7% (p = 0.02), and 34% (p < 0.001). Among patients < 75 years 26% were prescribed a beta blocker, 11% spironolactone, and 50% an angiotensin converting enzyme inhibitor. The corresponding figures for patients > or = 75 years were 19% (p = 0.04 versus patients < 75), 7% (p = 0.04), and 33% (p < 0.001). CONCLUSIONS: Heart failure is a common condition, especially with advancing age. In the elderly, the community burden of heart failure is at least as great as that of angina or hypertension. The high rate of concomitant respiratory tract infection emphasises the need for strategies to immunise patients with heart failure against influenza and pneumococcal infection. Drugs proven to improve survival in heart failure are used less frequently for elderly patients and women.

Influence of socioeconomic deprivation on the primary care burden and treatment of patients with a diagnosis of heart failure in general practice in Scotland: population based study.

OBJECTIVE: To examine whether there are socioeconomic gradients in the incidence, prevalence, treatment, and follow up of patients with heart failure in primary care. DESIGN: Population based study. SETTING: 53 general practices (307,741 patients) participating in the Scottish continuous morbidity recording project between 1 April 1999 and 31 March 2000. PARTICIPANTS: 2186 adults with heart failure. MAIN OUTCOME MEASURES: Comorbid diagnoses, frequency of visits to general practitioner, and prescribed drugs. RESULTS: 2186 patients with heart failure were seen (prevalence 7.1 per 1000 population, incidence 2.0 per 1000 population). The age and sex standardised incidence of heart failure increased with greater socioeconomic deprivation, from 1.8 per 1000 population in the most affluent stratum to 2.6 per 1000 population in the most deprived stratum (odds ratio 1.44, P = 0.0003). On average, patients were seen 2.4 times yearly, but follow up rates were less frequent with increasing socioeconomic deprivation (from 2.6 yearly in the most affluent subgroup to 2.0 yearly in the most deprived subgroup, P = 0.00009). Overall, 812 (80.6%) patients were prescribed diuretics, 396 (39.3%) angiotensin converting enzyme inhibitors, 216 (21.4%) beta blockers, 208 (20.7%) digoxin, and 86 (8.5%) spironolactone. The wide discrepancies in prescribing between different general practices disappeared after adjustment for patient age and sex. Prescribing patterns did not vary by deprivation categories on univariate or multivariate analyses. CONCLUSIONS: Compared with affluent patients, socioeconomically deprived patients were 44% more likely to develop heart failure but 23% less likely to see their general practitioner on an ongoing basis. Prescribed treatment did not differ across socioeconomic gradients.

A generic computer program for checking photon beam dose calculations.

A computer program for checking photon external beam dose calculations is described. It provides a check of the treatment planning calculation by the use of machine data that are independent of that used in the initial calculation. Data required to specify any radiation beam are easily and rapidly set up and the program works for all the major manufacturers' machines. The user interface uses an interactive screen for machine data input and also for dose checking, where dose calculation is performed in real time as data are entered. The dose resulting from the planned field parameters is calculated and compared with the prescribed dose with a warning provided if the agreement is outside a set range (+/-5%). Its purpose is to act as a final quality assurance check to ensure that no significant errors occur in the monitor unit calculation.

Trends in case-fatality in 22968 patients admitted for the first time with atrial fibrillation in Scotland, 1986-1995.

BACKGROUND: Although atrial fibrillation (AF) is an important cause of cardiovascular morbidity and mortality there is a paucity of data describing hospitalisation rates and case-fatality associated with this common arrhythmia. This study examines recent trends in first-ever hospitalisations for AF in Scotland. METHODS: Using the linked Scottish Morbidity Record Scheme, we identified all 22968 patients admitted to Scottish hospitals for the first time with a principal diagnosis of AF between 1986 and 1995. For each calendar year we calculated short (30-day) and medium (31 day to 2 years) case-fatality rates. Adjusting for each patient's age, sex, deprivation status, concurrent diagnoses and prior hospitalisation status, we examined whether case-fatality rates had significantly improved during this 10-year period. RESULTS: Between 1986 and 1995 the number of men hospitalised for the first time with AF increased by 926 (125%) to 1730 per annum and the number of women and by 875 (105%) to 1712 (both P<0.001). Hospitalisation rates increased from 0.31 to 0.70/1000 men and from 0.32 to 0.65/1000 women (both P<0.001). By the end of this period the proportion of men had increased from 48 to 50%. In both sexes, the median age of patients rose--in men from 66 to 68 years and in women from 74 to 75 years (both P<0.01). Despite the increasing age of patients and greater comorbidity, short-term (30-day) case-fatality declined from 4.0 to 3.1% in men (P<0.001) and 4.1 to 3.8% (P<0.01) in women. Similarly, medium-term (31-day to 2-year) case-fatality fell from 25 to 22% in men and 27 to 25% (both P<0.001) in women. Adjusting for the age, sex, extent of deprivation, secondary diagnoses and prior hospitalisation of hospitalised patients, we found that the risk of short-term case-fatality in the 1995 male and female cohort significantly declined by 21% (P<0.05) and 24% (P<0.05), respectively, in comparison to the 1986 cohort. The adjusted risk of case-fatality in the medium term also declined significantly in men by 30% (P<0.05) over this period and by 20% (P<0.05) in women relative to 1986. CONCLUSION: The number of first-ever hospitalisations for AF has increased twofold during the 10-year period 1986-1995. Although the age of patients has progressively increased during this period, short and medium case-fatality rates have declined, especially in men. This may partly reflect better treatment of AF. However, changing admission thresholds and other factors could also have led to an apparent improvement in prognosis. Nevertheless, medium-term case fatality remains substantial after a first ever admission to hospital with AF.

Age, sex, and social trends in out-of-hospital cardiac deaths in Scotland 1986-95: a retrospective cohort study.

BACKGROUND: Most deaths from coronary heart disease occur out of hospital. Hospital patients face social, age, and sex inequalities. Our aim was to examine inequalities and trends in out-of-hospital cardiac deaths. METHODS: We used the Scottish record linked database to identify all deaths from acute myocardial infarction that occurred in Scotland (population 5.1 million), in 1986-95. We have compared population-based death rates for men and women across age and social groups. FINDINGS: Between 1986 and 1995, 83365 people died from acute myocardial infarction, out of hospital and without previous hospital admission (44655 men, 38710 women); and 117749 were admitted with a first acute myocardial infarction, of whom 37020 died within 1 year. Thus, out-of-hospital deaths accounted for 69.2% (95% CI 69.0-69.5) of all 120385 deaths. Out-of-hospital deaths, measured as a proportion of all acute myocardial infarction events (deaths plus first hospital admissions), increased with age, from 20.1% (19.2-21.0) in people younger than 55 years, to 62.1% (61.3-62.9) in those older than 85 years. Population-based out-of-hospital mortality rates fell by a third in men and by a quarter in women. Mean yearly falls were larger in people aged 55-64 years (5.6% per year in men, 3.7% in women), than in those older than 85 years (2.5% in men and women). Mortality rates were substantially higher in deprived socioeconomic groups than in affluent groups, especially in people younger than 65 years. INTERPRETATION: These inequalities in age, sex, and socioeconomic class should be actively addressed by prevention strategies for coronary heart disease.

Gender and survival: a population-based study of 201,114 men and women following a first acute myocardial infarction.

OBJECTIVES: We tested the hypotheses that the effect of gender on short-term case fatality following a first admission for acute myocardial infarction (AMI) varies with age, and that this effect is offset by differences in the proportion of men and women who survive to reach hospital. BACKGROUND: Evidence is conflicting regarding the effect of gender on prognosis after AMI. METHODS: All 201,114 first AMIs between 1986 and 1995 were studied. Both 30-day and 1-year case fatality were analyzed for the 117,749 patients hospitalized and for all first AMIs, including deaths before hospitalization. The effect of gender and its interaction with age on survival was examined using multivariate modeling. RESULTS: Gender-based differences in survival varied according to age in hospitalized patients, with younger women having higher 30-day case fatality than men (e.g., <55 years, women 6.5% vs. 4.8% men, p < 0.0001). When deaths from first AMI before hospitalization were included in 30-day case fatality, women were less likely to die (adjusted odds ratio 0.9, confidence interval 0.89 to 0.93). Gender was not an independent predictor of one-year survival (p = 0.16). CONCLUSIONS: Female gender increases the probability of surviving to reach hospital, and this outweighs the excess risk of death occurring in younger women following hospitalization. Overall, men have a higher 30-day case fatality than women. Women do not fare worse than men after AMI when age and other factors are taken into account. However, men are more likely to die before hospitalization.

Trends in case-fatality in 117 718 patients admitted with acute myocardial infarction in Scotland.

OBJECTIVES: To analyse short- and long-term case-fatality trends following admission to hospital with a first acute myocardial infarction, in men and women between 1986 and 1995, after adjusting for risk factors known to influence survival. DESIGN: A Scottish-wide retrospective cohort study. SETTING: The Linked Scottish Morbidity Record Database was analysed. This contains accurate data on all hospital admissions since 1981, for the Scottish population of 5.1 million. It is linked to the Registrar General's death certificate data. SUBJECTS: All 117 718 patients admitted to Scottish hospitals with a principal diagnosis of first acute myocardial infarction (ICD-9 code 410) between 1986 and 1995. MAIN OUTCOME MEASURES: The outcome was death, both in and out of hospital, from any cause, at 30 days, 1 year, 5 and 10 years. RESULTS: Overall case-fatality following hospital admission with acute myocardial infarction was 22. 2%, 31.4%, 51.1% and 64.0% at 1 month, 1 year, 5 and 10 years, respectively. Multivariate analyses identified statistically significant independent prognostic factors. Thirty day mortality increased twofold for each decade of increasing age, and increased with any prior admission to hospital. When comparing the most deprived category to that of the most affluent, men had a 10% increased mortality (P<0.01), whilst women had an increased mortality of 4% (not significant). After adjustment for age, sex, deprivation and prior admission to hospital, case-fatality rates fell significantly between 1986 and 1995. Short-term case-fatality fell by 46% in men (27% in women) and long-term by 34% in men (30% in women) (both P<0.001). CONCLUSIONS: Population-based case-fatality rates in Scotland have fallen dramatically since 1986, particularly in men. The increasing survival in patients admitted to hospital suggests that the trial-based efficacy of modern therapies is now translating into population-based effectiveness. However, an individual's life expectancy still halves after a diagnosis of acute myocardial infarction. Of the variables that we could examine, age was the most powerful predictor of prognosis.

Evidence of improving prognosis in heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and 1995.

BACKGROUND: Contemporary survival in unselected patients with heart failure and the population impact of newer therapies have not been widely studied. Therefore, we have documented case-fatality rates (CFRs) over a recent 10-year period. METHODS AND RESULTS: In Scotland, all hospitalizations and deaths are captured on a single database. We have studied case fatality in all patients admitted with a principal diagnosis of heart failure from 1986 to 1995. A total of 66 547 patients (47% male) were studied. Median age was 72 years in men and 78 years in women. Crude CFRs at 30 days and at 1, 5, and 10 years were 19.9%, 44.5%, 76.5%, and 87.6%, respectively. Median survival was 1.47 years in men and 1.39 years in women (2.47 and 2. 36 years, respectively, in those surviving 30 days). Age had a powerful effect on survival, and sex, comorbidity, and deprivation had modest effects. One-year CF was 24.2% in those aged <55 years and 58.1% in those aged >84 years. After adjustment, 30-day CFRs fell between 1986 and 1995, by 26% (95% CI 15 to 35, P<0.0001) in men and 17% (95% CI 6 to 26, P<0.0001) in women. Longer term CFRs fell by 18% (95% CI 13 to 24, P<0.0001) in men and 15% (95% CI 10 to 20, P<0.0001) in women. Median survival increased from 1.23 to 1. 64 years. CONCLUSIONS: Heart failure CF is much higher in the general population than in clinical trials, especially in the elderly. Although survival has increased significantly over the last decade, there is still much room for improvement.

Measuring the costs and benefits of heart disease monitoring.

OBJECTIVE: To evaluate the costs and benefits of alternative systems of coronary heart disease monitoring in Scotland. DESIGN: An option appraisal was conducted to evaluate the costs and benefits of implementing a coronary heart disease monitoring system. This involved a review of existing Scottish datasets and relevant reports, specification of options, definition and weighting of benefit criteria by key stakeholders, assessment of options by experts, and costing of options. The options were assessed by 33 stakeholders (grouped as cardiologists, patient representatives, general practitioners, public health physicians, and policy makers), plus 13 topic experts. SETTING: Scotland (population 5.1 million). RESULTS: Between group mean benefit weights were: mortality rates and case fatality (10.6), quality of life (9.8), patient function (8.8), hospital activity (7.8), primary care activity (9.25), prescribing (5.72), socioeconomic impact (4.0), risk factors (7.4), prevalence (5.0), incidence (6.0), case registration (6.82), international comparability (4.2), breadth of coverage (8.8), and frequency (5.8). Differences between group weights were significant for prevalence (p = 0.048) and international comparability (p = 0.032). Four monitoring options were identified: a community epidemiology model, based on MONICA (monitoring trends and determinants in cardiovascular disease) study methodology applied to a series of eight representative communities, had the highest benefits, at an average annual discounted cost of approximately pound 360,000; models based on the Australian cardiovascular disease monitoring scheme and on enhanced routine data offered fewer benefits at discounted average annual costs ranging from pound 165,000 to pound 195,000; finally, a coronary heart disease registry modelled on the Scottish Cancer Registry scheme would have had fewer benefits and substantially higher costs than the other options. CONCLUSIONS: The most beneficial coronary heart disease monitoring system is the community epidemiology model, based on MONICA methodology. Option appraisal potentially offers an explicit and transparent methodology for evidence based policy development.