Stroke Laterality Bias in the Management of Acute Ischemic Stroke.

BACKGROUND: Little is known of the impact of stroke laterality on the management process and outcome of patients with acute ischemic stroke (AIS). METHODS: Consecutive patients admitted to a general hospital over 1 year with supratentorial AIS were eligible for inclusion in the study. Baseline characteristics and risk factors, delays in hospital admission, imaging, intrahospital transfer to an acute stoke unit, stroke severity and classification, length of hospital admission, as well as 10-year mortality were measured and compared among right and left hemisphere AIS patients. RESULTS: There were 141 patients (77 men, 64 women; median age 73 [interquartile range 63-79] years), There were 71 patients with left hemisphere AIS and 70 with right hemisphere AIS. Delays to hospital admission from stroke onset to neuroimaging were similar among right and left hemisphere AIS patients. Delay in transfer to an acute stroke unit (ASU) following hospital admission was on average 14 hours more for right hemisphere compared to left hemisphere AIS patients (P = .01). Laterality was not associated with any difference in 10-year survival. CONCLUSIONS: Patients with mild and nondominant AIS merit particular attention to minimize their intrahospital transfer time to an ASU.

Idiopathic Intracranial Hypertension in the Northwest of Northern Ireland: Epidemiology and Clinical Management.

BACKGROUND: There is limited literature on the epidemiology of idiopathic intracranial hypertension (IIH). The diagnosis and management of IIH require a multidisciplinary approach. We sought to study the incidence as well as prevalence of IIH and to evaluate the current management of IIH in the northwest of Northern Ireland. METHODS: Medical records of patients diagnosed with IIH between 2007 and 2014 in a general hospital in Northern Ireland were reviewed. Clinical and outcome data were retrieved. RESULTS: There were 45 patients with IIH, 44 women: 1 man. The mean age at presentation was 29.4 (SD 9.8) years and mean body mass index (BMI) 39.8 (SD 9.5) kg/ m(2). All patients had neuroimaging, 44 (98%) had CT/MR venogram and 41 (91%) had visual perimetry. The crude incidence of IIH was 2.36 per 100,000 (95% CI 1.65-3.37). For women, the incidence was 4.65 per 100,000/year (95% CI 3.25-6.66). The prevalence was 14.3 per 100,000 overall (95% CI 9.72-20.9) but 28.1 per 100,000 in women (95% CI 19.2-41.2). Visual field defects were identified in 25 of 41 (61%); 4 patients (9%) required shunting procedures. At follow-up, the mean BMI decreased by 1.6 kg/m(2) (p = 0.024). CONCLUSIONS: The incidence of IIH in the northwest of Northern Ireland is among the highest ever reported and probably reflects the known increase in obesity.

Clinical and diagnostic findings in patients with elevated cerebrospinal bilirubin.

INTRODUCTION: Cerebrospinal fluid (CSF) spectroscopy can identify subarachnoid haemorrhage (SAH) when CT is negative in patients presenting with acute severe headache. The primary objective of this study was to evaluate the clinical use and usefulness of CSF spectrophotometry. Secondary objectives were to identify other causes of elevated CSF bilirubin, to analyse headache descriptions and to compare clinical features in patients with an elevated CSF bilirubin among those with and without an intracranial vascular cause of SAH (avSAH). METHODS: Consecutive patients admitted to two hospitals in Enniskillen and Londonderry between 1 January 2004 and 30 September 2014 with CSF spectroscopy bilirubin results were identified from a clinical chemistry laboratory dataset. Patients with elevated CSF bilirubin were studied. Clinical demographics, delays to investigation and final diagnoses were recorded. Patients with avSAH were compared with patients without avSAH. RESULTS: Among 1813 patients with CSF spectrophotometry results, requests increased more than threefold during the study (p<0.001). Fifty-six patients had elevated CSF bilirubin. Ten (17.9%) had avSAH, of which 8 (14.3%) had aneurysmal SAH. Non-vascular causes of elevated CSF bilirubin included meningitis, spontaneous intracranial hypotension and carcinomatous meningitis. Headache descriptions varied. Time from headache onset to admission, CT scan and lumbar puncture did not differ significantly for patients with avSAH and non-avSAH. CSF red cell counts were higher among patients with avSAH than patients with non-avSAH (p=0.005). CONCLUSIONS: CSF bilirubin measurement has an important role in identifying avSAH in CT-negative patients presenting with a thunderclap headache. Better clinical selection of patients is required as CSF spectrophotometry, although sensitive, is not specific for SAH.

Bariatric surgery tourism in the COVID-19 era.

Background: Since the start of the Covid-19 pandemic primary and secondary health care services in Northern Ireland have observed an increase in the number of patients who have had bariatric surgery outside of the UK. This study sought to estimate the frequency of bariatric surgery tourism and to audit indications, blood monitoring and medical complications. Methods: All primary care centres within the Western Health Social Care Trust (WHSCT) were invited to document the number of patients undergoing bariatric surgery between January 1, 2017 and December 31, 2022. For one primary care centre, patients who underwent bariatric surgery were assessed against the National Institute of Health and Clinical Excellence (NICE) guideline indications for bariatric surgery. In addition, the blood monitoring of these patients was audited against the British Obesity and Metabolic Surgery Society (BOMSS) guidelines for up to two years following surgery. Medical contacts for surgical complications of bariatric surgery were recorded. Results: Thirty-five of 47 (74.5%) GP surgeries replied to the survey, representing 239,961 patients among 325,126 registrations (73.8%). In the six year study period 463 patients had reported having bariatric surgery to their GP. Women were more likely to have had bariatric surgery than men (85.1% versus 14.9%). There was a marked increase in the number of patients undergoing bariatric surgery with each year of the study (p<0.0001 chi square for trend). Twenty-one of 47 patients (44.7%) evaluated in one primary care centre fulfilled NICE criteria for bariatric surgery. The level of three-month monitoring ranged from 23% (for vitamin D) to 89% (electrolytes), but decreased at two years to 9% (vitamin D) and 64% (electrolytes and liver function tests). Surgical complication prevalence from wound infections was 19% (9 of 44). Antidepressant medications were prescribed for 23 of 47 patients (48.9%). Conclusions: The WHSCT has experienced a growing population of patients availing of bariatric surgery outside of the National Health Service. In view of this and the projected increase in obesity prevalence, a specialist obesity management service is urgently required in Northern Ireland.

Teaching recovery to medical students.

OBJECTIVES: Community mental health services are evolving toward more holistic, patient-centered, recovery-based practices. This change necessitates an attitudinal shift from mental health workers, and training in recovery principles is helpful in achieving this change. Medical students often have narrow, doctor-centered concepts of mental health care. Traditional clinical placements in psychiatry do little to address this. We evaluated a recovery-focused teaching program for medical students in psychiatry. METHOD: Medical students' knowledge of recovery from mental illness was assessed before and after either a 6-week traditional or recovery-focused clinical placement in psychiatry, using the Recovery Knowledge Inventory. A validated questionnaire was used to assess attitudes toward mental illness before and after the placements. Focus groups were conducted before and after the recovery teaching. RESULTS: One hundred nineteen medical students participated; 23 experienced the recovery teaching program while 96 had a traditional placement (23 in the same center as the recovery teaching program and 73 in other centers). There were no significant differences between groups at baseline. After recovery teaching, medical students significantly increased their recovery knowledge and had more positive attitudes toward mental illness and psychiatry when compared with those who had a traditional placement. The focus groups revealed greater optimism and more holistic concepts of recovery from mental illness. CONCLUSION AND IMPLICATIONS FOR PRACTICE: The recovery teaching program was associated with increased knowledge of recovery principles and more positive attitudes toward mental illness. Psychiatric clinical placements for medical students should include an explicit recovery focus.

Changes in HIV incidence in people who inject drugs in Ireland from 2000 to 2018: longitudinal observational study.

BACKGROUND AND AIMS: People who inject drugs (PWID) have a substantial risk of acquiring human immunodeficiency virus (HIV) infection. From 1999 to 2000 in Ireland, there were 115 new HIV cases among PWID, 40% in individuals aged under 22 years. However, over the past two decades, HIV incidence has declined among PWID in western Europe, including Ireland. We investigated secular changes in HIV incidence among PWID in Ireland. Also, new HIV cases in two time-periods 2000-09 and 2010-18 were compared by sex, age group, area of residence and country of birth. DESIGN AND SETTING: Longitudinal observational study in the Republic of Ireland, 2000-18. CASES AND MEASUREMENTS: A total of 753 new cases of HIV in PWID were diagnosed. Diagnosis rates of HIV in PWID were calculated and changes in rates over the period were modelled. FINDINGS: During the period 2000-18, HIV incidence among 15-29-year-old PWID in Ireland declined from 5.69 to 0.11 cases per 100 000, equivalent to a yearly decline of 0.22 [95% confidence interval (CI) = 0.14-0.31, P < 0.001] cases per 100 000. Among PWID aged 30-64 years, HIV incidence declined annually by 0.06 (95% CI = 0.02-0.10, P = 0.007) cases per 100 000 from 1.80 to 0.57 cases per 100 000. Comparing 2000-09 to 2010-18, there was a relative increase in HIV cases among older adults (P < 0.001), and those born outside Ireland accounted for a growing minority of cases (from 14.7 to 28.0%, P < 0.001). Changes by sex (P = 0.10) and area residence (P = 0.39) were not statistically significant. CONCLUSION: Since 2000, Ireland has achieved an ongoing reduction in the incidence of human immunodeficiency virus among PWID, and this is most evident among young adults. The reduction has occurred in the context of a reasonably comprehensive, health-led and harm reduction-orientated national drugs strategy.

The finding of reduced estimated glomerular filtration rate is associated with increased mortality in a large UK population.

BACKGROUND: CKD as defined by KDIGO/KDOQI has been shown to affect ~ 8.5% of the UK population. The prevalence of CKD in the UK is similar to that in the USA, yet incident dialysis rates are dramatically different. This retrospective cohort study investigates the association between reduced kidney function and mortality in a large UK population. METHODS: All serum creatinine results covering Northern Ireland's 1.7 million population were collected between 1 January 2001 and 31 December 2002. Estimated glomerular filtration rates (eGFR) were calculated for all serum creatinine measurements using four-variable MDRD equation (IDMS aligned). Patients were followed up for both all-cause and cardiovascular mortality data until the end of December 2006. Patients on renal replacement therapy were excluded. Subgroup analysis in the 75,345 subjects enrolled within a parallel primary care study permitted additional survival analysis with adjustment for traditional cardiovascular risk factors. RESULTS: A total of 1,967,827 serum creatinine results from 533,798 patients were collected. During the period of follow-up, 59,980 deaths occurred. In multivariate survival analysis, using eGFR as a time-varying covariate, a graded association between CKD (defined by eGFR) and all-cause mortality was identified. Compared with participants with an eGFR of > 60 mL/min/1.73 m(2), the adjusted hazard ratios (and 95% confidence intervals) for participants with an eGFR of 45-59 mL/min/1.73 m(2) was 1.02 (0.99-1.04), an eGFR of 30-44 mL/min/1.73 m(2) was 1.44 (1.40-1.47), an eGFR of 15-29 mL/min/1.73 m(2) was 2.12 (2.05-2.20) and an eGFR of < 15 mL/min/1.73 m(2) was 3.46 (3.24-3.70). Significantly, increased all-cause mortality was associated with an eGFR < 45 mL/min/1.73 m(2) following adjustment for age and gender. The association between cardiovascular mortality and reduced renal function continued to be significant for participants with an eGFR of 45-65 mL/min/1.73 m(2). Subgroup analysis in 75,345 individuals with more detailed clinical information available confirmed this association following adjustment for traditional cardiovascular risk factors in addition to age and gender. CONCLUSIONS: This study demonstrates a graded association between reduced renal function as represented by eGFR and mortality in a UK population. The all-cause and cardiovascular mortality risk increases sharply when estimated GFR falls < 45 mL/min/1.73 m(2). The association between an eGFR measured between 45 and 65 mL/min/1.73 m(2) and cardiovascular mortality persists in this cohort and highlights the ongoing uncertainty in accurately categorizing renal dysfunction.

A Neurodisparity Index of Nationwide Access to Neurological Health Care in Northern Ireland.

Nationwide disparities in managing neurological patients have rarely been reported. We compared neurological health care between the population who reside in a Health and Social Care Trust with a tertiary neuroscience center and those living in the four non-tertiary center Trusts in Northern Ireland. Using the tertiary center Trust population as reference, neurodisparity indices (NDIs) defined as the number of treated patients resident in each Trust per 100,000 residents compared to the same ratio in the tertiary center Trust for a fixed time period. NDIs were calculated for four neurological pathways-intravenous thrombolysis (iv-tPA) and mechanical thrombectomy (MT) for acute ischemic stroke (AIS), disease modifying treatment (DMT) in multiple sclerosis (MS) and admissions to a tertiary neurology ward. Neurological management was recorded in 3,026 patients. Patients resident in the tertiary center Trust were more likely to receive AIS treatments (iv-tPA and MT) and access to the neurology ward (p < 0.001) than patients residing in other Trusts. DMT use for patients with MS was higher in two non-tertiary center Trusts than in the tertiary center Trust. There was a geographical gradient for MT for AIS patients and ward admissions. Averaged NDIs for non-tertiary center Trusts were: 0.48 (95%CI 0.32-0.71) for patient admissions to the tertiary neurology ward, 0.50 (95%CI 0.38-0.66) for MT in AIS patients, 0.78 (95%CI 0.67-0.92) for iv-tPA in AIS patients, and 1.11 (95%CI 0.99-1.26) for DMT use in MS patients. There are important neurodisparities in Northern Ireland, particularly for MT and tertiary ward admissions. Neurologists and health service planners should be aware that geography and time-dependent management of neurological patients worsen neurodisparities.

Genetic epidemiology of spontaneous subarachnoid hemorrhage: Nordic Twin Study.

BACKGROUND AND PURPOSE: It would be essential to clinicians, familial aneurysm study groups, and aneurysm families to understand the genetic basis of subarachnoid hemorrhage (SAH), but there are no large population-based heritability estimates assessing the relative contribution of genetic and environmental factors to SAH. METHODS: We constructed the largest twin cohort to date, the population-based Nordic Twin Cohort, which comprised 79 644 complete twin pairs of Danish, Finnish, and Swedish origin. The Nordic Twin Cohort was followed up for 6.01 million person-years using nationwide cause-of-death and hospitalization registries. RESULTS: One hundred eighty-eight fatal and 321 nonfatal SAH cases were recorded in the Nordic Twin Cohort. Thus, SAH incidence was 8.47 cases per 100,000 follow-up years. Data for pairwise analyses were available for a total of 504 SAH cases, of which 6 were concordant (5 monozygotic and 1 opposite sex) and 492 discordant twin pairs for SAH. The concordance for SAH in monozygotic twins was 3.1% compared with 0.27% in dizygotic twins, suggesting at most a modest role for genetic factors in the etiology of SAH. The population-based probability estimate for SAH in dizygotic siblings of a patient with SAH is 0.54%, and only 1 of 185 full siblings experience familial SAH. The corresponding risk of SAH in monozygotic twins is 5.9%. Model-fitting, which was based on the comparison of the few monozygotic and dizygotic pairs, suggested that the estimated heritability of SAH is 41%. CONCLUSIONS: SAH appears to be mainly of nongenetic origin, and familial SAHs can mostly be attributed to environmental risk factors.

A systematic review of population based epidemiological studies in Myasthenia Gravis.

BACKGROUND: The aim was to collate all myasthenia gravis (MG) epidemiological studies including AChR MG and MuSK MG specific studies. To synthesize data on incidence rate (IR), prevalence rate (PR) and mortality rate (MR) of the condition and investigate the influence of environmental and technical factors on any trends or variation observed. METHODS: Studies were identified using multiple sources and meta-analysis performed to calculate pooled estimates for IR, PR and MR. RESULTS: 55 studies performed between 1950 and 2007 were included, representing 1.7 billion population-years. For All MG estimated pooled IR (eIR): 5.3 per million person-years (C.I.:4.4, 6.1), range: 1.7 to 21.3; estimated pooled PR: 77.7 per million persons (C.I.:64.0, 94.3), range 15 to 179; MR range 0.1 to 0.9 per millions person-years. AChR MG eIR: 7.3 (C.I.:5.5, 7.8), range: 4.3 to 18.0; MuSK MG IR range: 0.1 to 0.32. However marked variation persisted between populations studied with similar methodology and in similar areas. CONCLUSIONS: We report marked variation in observed frequencies of MG. We show evidence of increasing frequency of MG with year of study and improved study quality. This probably reflects improved case ascertainment. But other factors must also influence disease onset resulting in the observed variation in IR across geographically and genetically similar populations.

Inverse association between gastroesophageal reflux and blood pressure: results of a large community based study.

BACKGROUND: In a cross-sectional community based study, as part of a randomised controlled trial of eradication of Helicobacter pylori infection, the association between blood pressure and symptoms of gastro-oesophageal reflux was examined. METHODS: Linear regression was used to examine the association between systolic and diastolic blood pressure and the frequency of heartburn and acid regurgitation in 4,902 of 10,537 participants aged 20-59 years. RESULTS: In multivariable analyses, adjusted mean systolic blood pressure was 4.2 (95% confidence interval 1.5 to 7.0) mm Hg lower in participants with daily acid regurgitation compared to those with less frequent symptoms. Similarly, for diastolic blood pressure, a reduction of 2.1 (0.0 to 4.3) mm Hg wasobserved. CONCLUSION: People who experience daily symptoms of gastro-oesophageal reflux have lower blood pressure than people with less frequent or no symptoms. It is possible that factors influencing nitric oxide concentrations both at the lower oesophageal sphincter and within the vasculature may be involved. This hypothesis requires confirmation. TRIALS REGISTRATION NUMBER: ISRCTN44816925.

Prevalence of epigastric pain, heartburn and acid regurgitation in adolescents and their parents: evidence for intergenerational association.

BACKGROUND AND AIMS: Little is known of the epidemiology of upper gastrointestinal symptoms in adolescents. We examined the prevalence of, and the risk factors for, epigastric pain, heartburn and acid regurgitation in adolescents from Northern Ireland. PARTICIPANTS: A total of 1133 adolescents aged 12-18 years participated in this study. METHODS: Questionnaires were mailed to 2017 randomly selected individuals gathering information on symptoms of epigastric pain, heartburn and acid regurgitation. Prevalences of the symptoms in the individuals and their parents were calculated. Associations between potential risk factors such as age, sex, body mass index category, smoking and frequency of symptoms were examined for both adolescents and their parents. Logistic regression was used to examine the relationship between adolescent and parental symptoms. RESULTS: Symptoms of epigastric pain, heartburn and acid regurgitation were infrequent in adolescents, but were substantially more common in parents. Adolescents were more likely to experience these symptoms if either parent experienced them, the association being much stronger if both parents were symptomatic, for example, the odds ratio (95% confidence interval) for the individual having acid regurgitation if both parents had this symptom was 6.89 (1.32, 35.7). Symptoms were more likely in adolescents who smoked and whose parents smoked, who were from lower socioeconomic backgrounds, and who had higher body mass index. For parents, smoking was positively associated with all symptoms, whereas being overweight was related to frequency of heartburn and acid regurgitation. CONCLUSIONS: Strong relationships were seen between adolescent and parental reporting of dyspeptic symptoms. Although this could be due to intrafamilial clustering of environmental factors, the associations persisted after adjusting for these. Psychosocial factors or genetic predisposition may underlie the relationships. Further research is required to explore these relationships more fully.

Diagnostic test results in primary CNS vasculitis: A systematic review of published cases.

BACKGROUND: Primary CNS vasculitis (PCNSV) can be diagnosed using cerebral angiography or histopathology combined with clinical features. The original diagnostic criteria, which weigh each test equally, have not been validated. Limited sensitivity and specificity for biopsy and angiography are recognized. We systematically reviewed results of diagnostic tests performed in patients with an ultimate diagnosis of PCNSV. METHODS: We searched the OVID Medline database and bibliographies for original cases of PCNSV. We recorded demographics, diagnostic tests used, and assessed agreement between angiography and biopsy when both tests were performed. We also recorded MRI and CSF results. RESULTS: We found 701 original cases with PCNSV diagnosed with angiography or pathology. A total of 269 patients (38.4%) had both cerebral angiography and histopathologic testing (biopsy/postmortem). Classic angiographic features of vasculitis were associated with pathologic confirmation in just 32 patients (4.6%). Seventy-four patients (10.6%) with any abnormality on angiography had a normal biopsy, and 99 patients (14.1%) with abnormal biopsies had normal angiography. Brain MRI was abnormal in 505/541 patients (93.3%) and CSF was abnormal in 360/484 patients (74.4%). Increasing use of angiography and decreasing histopathologic testing were found over time. CONCLUSIONS: Cerebral angiography and pathologic tissue examination were undertaken in a minority of published cases with a diagnosis of PCNSV. When both diagnostic tests were performed, disagreement between them was more than 5 times more likely than agreement. Diagnostic criteria for PCNSV may require revision to classify the clinical, pathologic, and radiologic features of this condition more accurately.

Association of body mass index measured in childhood, adolescence, and young adulthood with risk of ischemic heart disease and stroke: findings from 3 historical cohort studies.

BACKGROUND: It is unclear whether early life body mass index (BMI; in kg/m(2)) is associated with adult cardiovascular disease. OBJECTIVE: The objective was to assess the association of early life BMI with the risk of ischemic heart disease (IHD) and stroke. DESIGN: The association between early life BMI and risk of adult mortality from IHD and stroke was assessed in 3 historical cohort studies in which height and weight had been assessed by using standard procedures. Participants were traced and linked to national mortality data. Participants in the 3 cohorts were born between 1922 and 1937, 1927 and 1956, and 1928 and 1950 and were aged 2-15, 9-18, and 16-22 y, respectively, at the time of assessment of their height and weight. RESULTS: Participants in all 3 cohorts had mean BMIs similar to those reported for contemporary children and young adults, but fewer of the cohort participants were overweight or obese. BMI was not associated with future risk of IHD or stroke in any cohort. The pooled (all 3 cohorts) adjusted hazard ratio per SD of early life BMI was 1.09 (95% CI: 1.01, 1.19) for IHD and 0.94 (95% CI: 0.82, 1.08) for stroke. The pooled hazard ratio of IHD when participants who were overweight or obese for their age were compared with all other participants was 1.34 (95% CI: 0.95, 1.91), and no association was found between overweight or obesity and stroke risk. The effects of BMI did not vary by cohort or by age. CONCLUSION: These results do not provide strong evidence that being overweight or obese in childhood is associated with future cardiovascular disease risk.

A prospective investigation of height and prostate cancer risk.

Greater adult height, which reflects a combination of early nutrition, exposure to androgens, growth hormones, and other factors during growth and development, as well as heredity, has been associated with increased prostate cancer risk in several observational studies, but findings have been inconsistent. We examined this relationship in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study cohort. At baseline, 29,119 Finnish male smokers 50 to 69 years old had height and weight measured by trained personnel, provided information on demographic, smoking, medical, and other characteristics, and completed an extensive diet history questionnaire. A total of 1,346 incident prostate cancer cases were identified during a follow-up period of up to 17.4 years (median, 14.1 years). In age-adjusted Cox proportional hazards models, the hazard ratios and 95% confidence intervals for prostate cancer according to increasing quintiles of height [178 cm] were 1.00 (reference), 1.11 (0.93-1.32), 1.11 (0.95-1.31), 1.30 (1.01-1.55), and 1.14 (0.96-1.35); P(trend) = 0.04. In analyses stratified by disease stage (available for 916 cases), a strong dose-response relationship was observed between greater height and advanced, but not earlier-stage, disease [tumor-node-metastasis stage III-IV, hazard ratio and 95% confidence interval for increasing quintiles of height: 1.77 (1.18-2.65), 1.82 (1.25-2.65), 1.93 (1.29-2.90), and 2.02 (1.37-2.97); P(trend) = 0.0008, P(interaction) = 0.002]. Our study provides additional evidence that increased height is a risk factor for prostate cancer and suggests that taller men are particularly susceptible to advanced disease.

Influence of mammographic screening on trends in breast-conserving surgery in Ireland.

Debate exists about the influence of screening on breast cancer surgery. We compared rates and odds of mastectomy and breast-conserving surgery (BCS) during 1994-1999 between Northern Ireland, which has had organized mammographic screening (age group 50-64) since 1993, and the Republic of Ireland, where large-scale screening did not begin until 2000. Trends in BCS were similar in both populations: significant increases in BCS rates for age groups 20-49 and, especially, 50-64, and significant increases in mastectomy rates for age group 65+ only. Use of BCS among surgical patients was significantly higher in Northern Ireland (46%) than the Republic of Ireland (35%) and, in Northern Ireland, was significantly higher in age group 50-64 than other age groups. Geographic and age-related variations were substantially, but not wholly, explained by tumour characteristics and screen-detection status. Among Northern Ireland women aged 50-64, BCS use among screen-detected cases, even after adjustment for tumour characteristics, was 40-50% higher and increased more rapidly during 1994-1999 than among other cases. However, trends in BCS in Northern Ireland were not explained by changes in screen-detection status or tumour characteristics. Our findings are consistent with expectations that mammographic screening, together with modern treatment guidelines, should lead to reduced use of mastectomy and increased (proportional) use of BCS. But similar trends occurred in the absence of large-scale screening (in the Republic of Ireland), and surgical treatment of screen-detected cases did not reflect tumour characteristics alone.

Trends in cervical squamous cell carcinoma incidence in 13 European countries: changing risk and the effects of screening.

Despite there being sufficient evidence for the effectiveness of screening by cytology in preventing cancer of the cervix uteri, screening policies vary widely among European countries, and incidence is increasing in younger women. This study analyzes trends in squamous cell carcinoma (SCC) of the cervix uteri in 13 European countries to evaluate effectiveness of screening against a background of changing risk. Age-period-cohort models were fitted and period and cohort effects were estimated; these were considered as primarily indicative of screening interventions and changing etiology, respectively. A unique set of estimates was derived by fixing age slopes to one of several plausible age curves under the assumption that the relation between age and cervical cancer incidence is biologically determined. There were period-specific declines in cervical SCC in several countries, with the largest decreases seen in northern Europe. A pattern emerged across Europe of escalating risk in successive generations born after 1930. In the western European countries, a decrease followed by a stabilization of risk by cohort was accompanied by period-specific declines. In southern Europe, stable period, but increasing cohort trends, were observed. Substantial changes have occurred in cervical SCC incidence in Europe and well-organized screening programs have been highly effective in reducing the incidence of cervical SCC. Screening and changing sexual mores largely explain the changing period- and cohort-specific patterns, respectively. The increasing risk in recent cohorts is of obvious concern particularly in countries where no screening programs are in place. Further investigation of the effectiveness of opportunistic screening is warranted as is the observation of differing risk patterns in young cohorts in countries with relatively similar societal structures.

Does psychological distress predict the risk of ischemic stroke and transient ischemic attack? The Caerphilly Study.

BACKGROUND AND PURPOSE: Psychological distress is common after stroke, but little is known about its etiologic importance, although the general public often ascribes stroke to the experience of stress. Therefore, we examined whether psychological distress leads to an increased risk of ischemic stroke and transient ischemic attack (TIA). METHODS: The association between the 30-item General Health Questionnaire (GHQ), a measure of psychological distress, and the incidence of nonfatal and fatal ischemic stroke and TIA was measured by Cox regression modeling in a prospective observational study of 2201 men aged 45 to 59 years in phase II of the Caerphilly cohort. Hazard ratios comparing those with high (> or = 5) and normal GHQ scores were calculated with adjustment for age and other covariates. RESULTS: Twenty-two percent of men suffered from psychological distress, indicated by a score of > or =5 on the GHQ. There were 130 incident strokes recorded, of which 17 were fatal and 113 nonfatal. The relative risk of incident ischemic stroke was 1.45 (95% CI, 0.98 to 2.14) for those who showed symptoms of psychological distress compared with those who did not. For fatal stroke the relative risk was 3.36 (95% CI, 1.29 to 8.71) and for nonfatal stroke 1.25 (95% CI, 0.82 to 1.92). The relative risk of TIA for the distressed group was 0.63 (95% CI, 0.26 to 1.53). The results were unchanged after adjustment for body mass index, systolic blood pressure, smoking, heavy drinking, social class, and marital status. However, additionally controlling for previously diagnosed ischemic heart disease, diabetes, respiratory disease, and retirement due to ill health attenuated the relative risks, but not markedly. For fatal strokes the relative risk decreased to 2.56 (95% CI, 0.97 to 6.75) when all confounding variables were included in the model. There was a graded association between degree of psychological distress and risk of fatal ischemic stroke. CONCLUSIONS: Psychological distress is a predictor of fatal ischemic stroke but not of nonfatal ischemic stroke or TIA. Further work examining the mechanisms of this association is required.

The changing global patterns of female breast cancer incidence and mortality.

One in ten of all new cancers diagnosed worldwide each year is a cancer of the female breast, and it is the most common cancer in women in both developing and developed areas. It is also the principal cause of death from cancer among women globally. We review the descriptive epidemiology of the disease, focusing on some of the key elements of the geographical and temporal variations in incidence and mortality in each world region. The observations are discussed in the context of the numerous aetiological factors, as well as the impact of screening and advances in treatment and disease management in high-resource settings.