Influence of rurality, deprivation and distance from clinic on uptake in men invited for abdominal aortic aneurysm screening.

BACKGROUND: Effective abdominal aortic aneurysm (AAA) screening requires high uptake. The aim was to assess the independent association of screening uptake with rurality, social deprivation, clinic type, distance to clinic and season. METHODS: Screening across Grampian was undertaken by trained nurses in six community and three hospital clinics. Men aged 65 years were invited for screening by post (with 2 further reminders for non-responders). AAA screening data are stored on a national call-recall database. The Scottish postcode directory was used to allocate to all invited men a deprivation index (Scottish Index of Multiple Deprivation), a Scottish urban/rural category and distance to clinic. Multivariable analysis was undertaken. RESULTS: The cohort included 5645 men invited for screening over 12 months (October 2012 to October 2013); 42·6 per cent lived in urban areas, 38·9 per cent in rural areas and 18·5 per cent in small towns (uptake 87·0, 89·3 and 90·8 per cent respectively). Overall uptake was 88·6 per cent with 76 new AAAs detected: 15·2 (95 per cent c.i. 11·8 to 18·6) per 1000 men screened. Aberdeen city (large urban area) had the lowest uptake (86·1 per cent). Uptake declined with increasing deprivation, with the steepest decline in urban areas. On multivariable analysis, a 1-point increase in deprivation deciles was associated with a 0·08 (95 per cent c.i. 0·06 to 0·11) reduction in the odds of being screened (P < 0·001). Clinic type (community versus hospital), distance to clinic and season were not associated independently with uptake. CONCLUSION: Both urban residence and social deprivation were associated independently with uptake among men invited for AAA screening.

Physical inactivity and arterial dysfunction in patients with rheumatoid arthritis.

OBJECTIVES: The increased risk of cardiovascular (CV) disease associated with rheumatoid arthritis (RA) is partly attributable to chronic inflammation, but traditional CV risk factors such as physical inactivity are also likely to be important. This study assessed the cross-sectional relationship between physical activity (PA) and arterial dysfunction in patients with RA. METHODS: Participants free of overt arterial disease aged 40-65 years were recruited from a consecutive series of RA patients attending a rheumatology clinic. A research nurse measured the 'augmentation index' (AIX%) on a single occasion (a higher AIX% indicates arterial dysfunction) using SphygmoCor radial pulse wave analysis (PWA) according to current recommendations. Participants provided a fasting blood sample and self-completed a patient questionnaire that included the modified Godin PA score (mGPAS). Analysis was adjusted for age, sex, CV and rheumatological factors using multiple linear regression. RESULTS: Among 114 patients (mean age 54 years, median arthritis duration 10 years, 82% women), mean AIX% was 31.5 (SD 7.7) and median mGPAS 15 (IQR 10-35). AIX% was correlated with mGPAS (rho -0.21, p = 0.02). AIX% decreased with more frequent vigorous PA. On unadjusted analysis, a 10-point higher mGPAS was associated with a -0.9 [95% confidence interval (CI) -1.3 to -0.4, p = 0.0005] lower AIX%. On adjusted analysis, the reduction was attenuated to -0.5 (95% CI -0.8 to -0.1, p = 0.03). CONCLUSIONS: A higher level of self-reported PA in RA patients is associated with a lower level of arterial dysfunction independently of other CV and rheumatological factors. Longitudinal studies are required to demonstrate that increased PA improves arterial dysfunction in RA patients.

Cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer.

Increasing duration of tamoxifen therapy improves survival in women with breast cancer but the impact of adherence to tamoxifen on mortality is unclear. This study investigated whether women prescribed tamoxifen after surgery for breast cancer adhered to their prescription and whether adherence influenced survival. A retrospective cohort study of all women with incident breast cancer in the Tayside region of Scotland between 1993 and 2002 was linked to encashed prescription records to calculate adherence to tamoxifen. Survival analysis was used to determine the effect of adherence on all-cause mortality. In all 2080 patients formed the study cohort with 1633 (79%) prescribed tamoxifen. The median duration of use was 2.42 years (IQR=1.04-4.89 years). Longer duration was associated with better survival but this varied over time. The hazard ratio for mortality in relation to duration at 2.4 years was 0.85, 95% CI=0.83-0.87. Median adherence to tamoxifen was 93% (interquartile range=84-100%). Adherence <80% was associated with poorer survival, hazard ratio 1.10, 95% CI=1.001-1.21. Persistence with tamoxifen was modest with only 49% continuing therapy for 5 years of those followed up for 5 years or more. Increased duration of tamoxifen reduces the risk of death, although one in two women do not complete the recommended 5-year course of treatment. A significant proportion of women have low adherence to tamoxifen and are at increased risk of death.

Gender inequalities in the management of angina pectoris: cross-sectional survey in primary care.

BACKGROUND AND AIMS: To determine the extent of gender differences in the routine clinical care of patients with angina pectoris in primary care. METHODS: A cross-sectional survey of general practitioner (GP) medical records undertaken by trained data managers in 6 GP practices. 925 adults (489 men) with a clinical diagnosis of angina (prevalence = 2.4%, 95%CI 2.3-2.6). Data extracted included: level of care; risk factor recording; prescribed medication; exercise ECG and coronary revascularisation. Adjusted male-to-female odds ratios (AOR) adjusted for age, angina duration, and previous myocardial infarction, (MI). RESULTS: Women with angina were older than men (71 v 65 years) with a lower prevalence of MI (30% v 45%), but a longer duration of angina (5 v 4 years). Men were more likely to receive once daily aspirin (AOR = 2.07, 95%CI 1.56-2.74) and be prescribed triple anti-anginal therapy (1.58, 95%CI 1.03-2.42). Men were also significantly more likely to undergo exercise ECG (1.56, 95%CI 1.14-2.15) and surgical revascularisation (1.71, 95%CI 1.03-2.85). Women tended to receive GP care alone (AOR =0.64, 95%CI 0.46-0.89), whilst men received specialist cardiac care (1.47, 95%CI 1.09-2.00). Beta-blocker use following MI was similar (0.99, 95%CI 0.59-1.69). CONCLUSION: Differences in the management of men and women are unaccountedfor by differences in age, previous MI or duration of angina. Gender differences in management of CHD reported from secondary care may also exist in primary care.

Arterial dysfunction in patients with rheumatoid arthritis and the consumption of daily fruits and daily vegetables.

BACKGROUND/OBJECTIVES: Rheumatoid arthritis (RA) is associated with increased arterial dysfunction and increased risk of cardiovascular disease. Regular fruit and vegetable consumption prevents cardiovascular disease, but their influence on arterial dysfunction in RA has not been investigated. We assessed the relationship between daily fruit-vegetable consumption and arterial dysfunction in this high-risk group. SUBJECTS/METHODS: Participants were recruited from a consecutive series of RA patients aged 40-65 years without overt cardiovascular disease attending rheumatology clinics. Standardised research nurse assessment included SphygmoCor pulse wave analysis using radial applanation tonometry (a higher augmentation index (AIX%) indicates arterial dysfunction), fasting blood sample, patient questionnaire and medical record review. Multivariable analysis was used to adjust for age, sex, cholesterol, mean arterial blood pressure, smoking habit, alcohol consumption, physical activity, cumulative inflammatory burden, rheumatoid nodules, disability and education. RESULTS: We recruited 114 RA patients: 81% female, mean age 54 years, median arthritis duration 10 years and mean AIX% 31.5 (s.d. 7.7). Fruit and vegetable consumption were significantly correlated (Spearman's rho 0.54, P≪0.0001) and on unadjusted analysis daily fruit and vegetable consumption was associated with a lower AIX% (-3.2; 95% CI -6.4 to -0.1, P=0.05). On adjusted analysis AIX% was lower with daily vegetable (-4.2; 95% CI -7.9 to -0.5; P=0.003), but not with daily fruit (-0.02; 95% CI -3.9 to 3.8; P=0.99) consumption. CONCLUSIONS: Daily vegetable consumption, but not daily fruit consumption, was independently associated with more favourable arterial function in patients with RA. These findings are consistent with the enterosalivary circulation of nitrate having an influence on arterial function.

Constitutional symptoms at the onset of rheumatoid arthritis and subsequent arterial stiffness.

The onset of rheumatoid arthritis (RA) can be associated with constitutional symptoms. Systemic inflammation may be a common factor behind such symptoms and the subsequent development of arterial disease. The aim of this study was to determine if a relationship exists between constitutional symptoms and arterial stiffness. We recruited 103 ambulatory RA patients (85 female) without overt arterial disease aged between 40 and 65 years attending hospital clinics. A research nurse measured arterial stiffness (heart rate standardised augmentation index, AIX) using the 'SphygmoCor' device, fasting lipids and erythrocyte sedimentation rate (ESR). Assessment included patient recall of constitutional symptoms at arthritis onset (aching muscles, tiredness, generalised weakness, low mood/depression, fever, loss of weight, loss of appetite) and a detailed medical record review. Regression analysis was used to adjust mean differences in AIX in the presence/absence of constitutional symptoms for current age, sex, arthritis duration, age arthritis onset, study ESR, ever smoked, mean arterial blood pressure (BP), treated hypertension and cholesterol. Mean age was 54 years (age arthritis onset 42 years), brachial BP 125/82 mmHg, cholesterol 5.4 mmol/L, ever smoked 59%, median RA duration 9 years, median ESR 16 mm/h and mean AIX 31.7 (SD 7.8). Unadjusted mean difference in AIX was -0.7 (95%CI -4.5 to 3.1; p = 0.72) in the presence of constitutional symptoms and the adjusted mean difference was -0.1 (-3.2 to 2.9; p = 0.93). No individual symptoms were significantly associated with increased arterial stiffness. In conclusion, we found no convincing association between constitutional symptoms at the onset of arthritis and subsequent arterial stiffness.

Repeatability of the measurement of augmentation index in the clinical assessment of arterial stiffness using radial applanation tonometry.

OBJECTIVE: Aortic augmentation index (AIx) measured using applanation tonometry is a non-invasive indicator of arterial stiffness. The objective of this study was to assess its repeatability when used by nurses with limited experience of the technique. MATERIAL AND METHODS: Blood pressure/augmentation index (BP/AIx) was measured 4 times in 20 consecutive ambulant patients (16 male) after they rested supine for 15 min. Two nurses independently and alternately measured BP/AIx using the same equipment (Omron HEM-757; SphygmoCor with Millar hand-held tonometer). Nurses were blinded to patient medical records and their colleague's AIx/BP. 'Within' and 'between' observer differences were assessed using intra-class correlation coefficients (rI) and 95 % limits of agreement (95 % LoA) derived from Bland-Altman plots. RESULTS: Mean age was 56 (mean BP 136/79; mean pulse 64). Mean AIx was 24.1 (range 2.8 to 41.0). Both 'between' and 'within' observer repeatability was very high, with intra-class correlation coefficients ranging from 0.92 to 0.98. Mean AIx readings 'between' observers differed by only 0.68 (95 % CI -0.24 to 1.59) with a high rI (0.98; 95 % CI 0.95 to 0.99) and a narrow 95 % LoA (-3.22 to 4.57). The 95 % LoA for 'within' observer repeatability was -6.75 to 7.95. Differences in AIx measurement did not vary over time or with increasing levels of AIx. CONCLUSIONS: Even when undertaken by relatively inexperienced operators, both 'within' and 'between' observer repeatability of AIx measurement is very high. Such non-invasive assessment of arterial stiffness has the potential to be included in the clinical assessment of ambulant patients.

Contributory factors to traffic accident deaths identified at coroner's inquest.

BACKGROUND: Road traffic accidents (RTAs) are an important public health problem and the collection of local information is central to successful accident initiatives in a district. As the local coroner is responsible for investigating accidental deaths, the coroner's inquest files are a potentially useful source of information in developing a district strategy to reduce accidents. METHODS: A consecutive series of fatal RTAs occurring within the city of Liverpool (1990-1992) were identified and the inquest records of the city coroner reviewed retrospectively to describe the local pattern of fatal RTAs and identify contributory factors. RESULTS: A total of 95 deaths were reviewed. Deaths predominantly involved pedestrians (72) and private cars (70), on roads where the speed limit was 30 m.p.h. (75), often on the main arterial roads of the city (53). Important contributory factors included alcohol consumption by the fatality (31), unsafe driving (31), unlit street lighting at night (16), and pedestrians failing to look (12). Both alcohol consumption and unsafe driving prominently involved younger adult males. More than two-thirds (64/95) of deaths had one or more contributory factors identifiable from inquest records. CONCLUSIONS: Coroner inquest records provide a useful source of information to identify opportunities and priorities for preventing fatal RTAs in a district. The subsequent accident strategy for Liverpool, part of the City Health Plan, advocates a co-ordinated approach that includes engineering measures to reduce vehicle speeds and protect pedestrians, measures to address driver attitudes, and the enforcement of current legislation in relation to alcohol and speeding.

Identification and characteristics of victims of violence identified by emergency physicians, triage nurses, and the police.

OBJECTIVES: The objectives of the study were threefold-to evaluate the identification and characteristics of victims of assault who attend an accident and emergency (A&E) department; to compare the total number of assaults recorded in the A&E department with the number recorded by the police; and to assess a system for collecting the location and method of assault. SETTING: The A&E department of Chorley and South Ribble Hospital Trust, Lancashire, England. METHODS: A three month prospective study was performed. Victims of violence recorded on computer by doctors at discharge were compared with those identified at initial nurse triage. A comparison of police data with the A&E data relating to Chorley residents was performed. Additional information on the method and location of assault was also collected. RESULTS: During the period 305 (2.6%) of the patients attending A&E were identified as having been assaulted. Of the 305 individuals, 236 (77%) were identified by a doctor while 173 (57%) such patients were identified by a triage nurse. A&E identified twice the number of assaults involving Chorley residents as the police. Both men and women were most likely to have been injured on the street (44% and 37% respectively), although a greater proportion of women were injured at home (24%) than men (10%). The majority of injuries were sustained by blows from fists, feet, and heads (73%). CONCLUSIONS: A&E doctors identify significantly more patients as the victims of violence than do nurses at triage. Using A&E data identifies assaulted individuals not identified by the police. Computer systems can be used in A&E to provide a more complete picture of the occurrence of violence in the community.

Violence in the community: a health service view from a UK Accident and Emergency Department.

A retrospective analysis of information recorded on victims of assault, who attended the Accident and Emergency department of Chorley and South Ribble Hospital over a 1 y period, was performed in order to describe the epidemiology of violent assault. During the year 735 (1.7%) of the patients attending A&E were identified as being victims of assault (71% were male). Victims were predominantly in their late teens and early 20s (median age 23 y, inter-quartile range 17 to 32 y). They attended at weekends (44% on Saturday or Sunday) and predominantly between the hours of 8 pm and 4 am (54%). Minor injuries were the most frequent (43%) while 21% of victims sustained lacerations and 11% had a fracture. The commonest site of injury was to the neck, face and throat (55%). The crude rate of attendance following violent assault for Chorley District was 4.67 per 1000 population per year. Information routinely collected by A&E departments can be used to describe the epidemiology of violence in the community. Further work is required to ascertain the optimal method of collection and dissemination of this information.

Deprivation and violence in the community: a perspective from a UK Accident and Emergency Department.

Using routinely collected data from an Accident and Emergency department over a 12 month period, we demonstrated a strong correlation (Pearson Correlation Coefficient 0.90; 95% Confidence Intervals, 0.77-0.96) between material deprivation and attendance following violent assault.

Acceptability of asking patients about violence in accident and emergency.

OBJECTIVES: To assess the acceptability to patients attending accident and emergency (A&E) of routine questioning about violence. METHODS: A questionnaire survey (15 questions; 5 point Likert scale) was distributed to a representative sample of all adult patients attending a district general hospital A&E department, Lancashire, England over a seven day period. RESULTS: 303 questionnaires were distributed and 281 returned questionnaires were available for analysis. Some 67% (95%CI 60% to 74%) of patients agreed that people attending A&E should routinely be asked about whether they have been assaulted. Altogether 89% (95%CI 85% to 93%) thought that health care staff should encourage victims of abuse or violence to inform the police, while 74% (95%CI 68% to 80%) thought that health care staff should routinely inform the police. While only 45% (95%CI 36% to 54%) of patients thought that people who had been assaulted would be likely to tell if asked, 81% (95%CI 76% to 86%) thought that if they themselves were victims they would tell if asked directly. CONCLUSIONS: Patients attending A&E departments support routine questioning by doctors and nurses about violence. They also support health professionals routinely informing the police in cases of violence. Further research is required into the outcomes of routine and direct questioning in A&E of patients about their exposure to violence.